Worland Health and Rehabilitation

Based on observation, medical record, and staff and resident interview, the facility failed to ensure medications were safely stored for 1 of 3 residents (#1) reviewed for medication administration. The census was 64. The findings were: Based on observation, medical record, and staff and resident interview, the facility failed to ensure medications were safely stored for 1 of 3 residents (#1) reviewed for medication administration. The census was 64. The findings were: 1. Review of the medical record showed resident #1 had diagnoses that included chronic kidney disease, hypertension, and atherosclerotic heart disease. The following concerns were identified: a. Observation on 4/30/26 at 12:14 PM showed resident #1 had an unlabeled medication cup that contained 1 unmarked white pill. b. Interview with resident #1 on 4/30/26 at 12:14 PM revealed a traveling nurse gave him/her a sodium chloride salt pill a few months ago. The resident reported s/he had high blood pressure (BP) and noticed the pill was not the sodium bicarbonate that s/he had been prescribed, and stated s/he refused 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 observation, staff interview, and policy and procedure review, the facility failed to ensure infection control techniques were utilized in 1 of 4 units. The findings were: 1. Observation on 4/30/26 at 6:01 AM showed CNA #1 exited room [ROOM NUMBER] with unbagged, soiled bed linens in her hands. She walked down the hall with the soiled linens and put them in the dirty linen bin. 2. Interview with the DON on 4/30/26 at 10:40 AM confirmed soiled linens should be put in a bag before leaving the room. 3. Review of the facility policy titled Soiled Laundry and Bedding last revised February 2026 showed .3. Place and transport contaminated laundry in bags or containers in accordance with established policies governing the handling and disposal of contaminated items .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident representative interview, medical record review, facility investigation review, Office of Healthcare Licensing and Surveys ([NAME]) incident report log review, and policy and procedure review, the facility failed to report an injury of unknown source within 2 hours to the State Agency for 1 of 3 sample residents (#1) reviewed for allegations of abuse. The census was 64. The findings were:1. Review of the 11/30/25 quarterly MDS assessment showed the resident had diagnoses which included non-Alzheimer's dementia, anxiety, and depression. The resident had a BIMS assessment of 0 which indicated severe cognitive impairment. The resident was coded as having no falls since admission/entry or the prior assessment. The following concerns were identified:a. Review of a facility reported incident (FRI) dated 3/4/26 showed an allegation of an injury of unknown source occurred on 3/3/26 at 9:40 PM. The staff was made aware on 3/3/26 at 9:43 PM, and the administrator was made aware on 3/3/26 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and provider interview, the facility failed to ensure a safe and orderly discharge from the facility for 1 of 3 sample residents (#2) reviewed for discharge. The findings were:1. Review of the 3/19/26 admission MDS assessment showed resident #2 was admitted to the facility on [DATE]. Review of the initial care plan showed the resident had diagnoses which included nontraumatic hematoma of soft tissue, congestive heart failure (CHF), urinary tract infection (UTI), and mild cognitive impairment. Review of the medical record showed the resident was discharged from the facility on 3/30/26 at 1:30 PM. The following concerns were identified:a. Review of the Physician Medicare Certification dated 3/19/26 and signed by the physician on 3/24/26 showed the resident required daily care for skilled rehab and skilled nursing, and the physician recommended post-SNF care at an assisted living facility (ALF).b. Review of the care conference minutes dated 3/20/26 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview, facility incident investigation review, state survey agency incident database review, and policy review, the facility failed to report allegations of misappropriation of resident property for 1 of 3 sample residents (#59) reviewed for abuse, neglect, and misappropriation. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #59 had a brief interview for mental status score of 14 out of 15 which indicated the resident was cognitively intact. The following concerns were identified: a. Interview with the resident on 3/4/25 at 11:23 AM revealed s/he had $200 which was missing and had told a housekeeper about it. The resident revealed the money went missing about 3 weeks ago and the money had not been found, returned, or replaced. b. Review of the state survey agency incident database review showed no evidence the allegation of missing money was reported. c. Review of an Investigator Interview Form dated 2/10/25 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, facility activities calendar review and policy and procedure review, the facility failed to provide an activities program designed to support residents in their choice of activities for 1 of 2 sample residents (#48) with activity concerns. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #48 had a diagnosis of dementia with behavioral symptoms such as hitting, kicking and wandering. Further review showed it was very important to the resident to do things with groups of people, very important to go outside when the weather was good, and somewhat important to do his/her favorite activities. The resident had a brief interview for mental status score of 5 out of 15, which indicated severe cognitive impairment. Review of the care plan last revised on 2/26/25 showed [the resident is] dependent on staff for meeting emotional, intellectual, physical, spiritual and social needs interventions which included Provide 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 observation, medical record review, and staff and resident interview, the facility failed to ensure resident diet orders were followed for 1 of 3 sample residents (#50) reviewed for food and nutrition. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #50 had a brief interview for mental status score of 15 out of 15, which indicated the resident was cognitively intact, and diagnoses which included diabetes mellitus. Further review showed the resident was coded for a therapeutic diet. Review of the resident's physician orders showed the resident was to receive a controlled carbohydrate diet, had fingerstick blood sugar checks before meals and as needed, and received insulin per a sliding scale based on fingerstick blood sugar levels. The following concerns were identified: a. Observation on 3/4/25 at 8:36 AM showed the resident received a full cinnamon roll with glaze that was visible on top of the roll and on the plate. Review of the diet card provided with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, professional standard review, and policy review, the facility failed to ensure infection prevention practices were implemented for 1 of 2 sample residents (#2) observed during personal care. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #2 had a brief interview for mental status score of 5 out of 15, which indicated severe cognitive impairment, and diagnoses which included cerebrovascular accident and hemiplegia or hemiparesis. Further review showed the resident was frequently incontinent of bowel and bladder and was dependent on staff for toileting hygiene and personal hygiene. The following concerns were identified: a. Observation on 3/5/25 at 2:22 PM showed CNA #1 and OT #1 assisted the resident into bed. The staff members removed the resident's soiled pants and CNA #1 placed the pants on the floor by the bed. The CNA performed incontinence care and, without removing the soiled gloves, the CNA touched the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview, facility investigation review, and policy and procedure review, the facility failed to protect the resident's right to be free from sexual abuse by another resident for 1 of 3 sample residents (#65) reviewed for abuse. The facility implemented corrective actions and was determined to be in substantial compliance as of 11/22/23. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #65 had moderate memory impairment and diagnoses which included non-Alzheimer's dementia, depression, and generalized muscle weakness. Further review showed the resident required extensive physical assistance of one person for mobility, transfers, dressing, toileting, and locomotion off the unit. Review of the behavior care plan provided by the DON on 12/20/23 showed Resident was involved in an event with a [male/female] resident where the [male/female] resident began to touch [him/her] inappropriately. Although resident is alert 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 observation, staff interview, review of facility policy, and review of the 2017 U.S. Public Health Service food code, the facility failed to ensure sanitary meal service during 1 of 2 meal observations (evening meal on 10/24/22). The facility census was 64. The findings were: 1. Observation on 10/24/22 at 5:32 PM showed dietary aide #1 delivered several trays to residents. During the observation the dietary aide placed plates of food for the residents on the table and assisted with dinner ware. The aide adjusted resident clothing, touching the residents' faces, arms, and hands. After coming in contact with residents' clothing, face, arms, and hands, the dietary aide assisted 2 additional residents with their food by placing her hands on the residents' sandwiches and cutting them in half. No hand hygiene was performed prior to touching the sandwiches. 2. Interview with the infection preventionist on 10/26/22 at 1:57 PM revealed all staff were trained in hand hygiene on an annual basis and there was an active hand hygiene monitoring program in place. Further interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy and procedure review, the facility failed to ensure appropriate safety devices were utilized during transfers for 1 of 3 sample residents (#9) reviewed for falls. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #9 had short-term and long-term memory problems and diagnoses which included arthritis, malnutrition, abnormalities of gait and mobility, pain, and fatigue. Further review showed the resident required extensive physical assistance of 2 or more people for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of the ADL care plan last revised on 7/27/22 showed the resident had abnormal gait, cognitive deficits, increased risk for falls, a decline in abilities, and history of complaints of discomfort to the left shoulder joint. Interventions included .Transfer: The resident requires (limited to extensive assistance by (1) staff to move between surfaces as necessary .Toilet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview and policy review the facility failed to ensure appropriate infection prevention practices during 1 of 2 observations of wound dressing changes (which affected resident #166). The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #166 was admitted with diagnoses which included cardiorespiratory debility condition, dementia, and stage 2 pressure ulcer. Further review showed the resident was admitted with one unstageable pressure injury. Review of the progress notes for resident #166 showed dressing changes for two open wound areas on the buttocks were performed twice a week on Tuesdays and Fridays. Observation on 10/25/22 at 5:20 PM showed RN #1 performed a dressing change on the resident's pressure injury and an abrasion to the resident's coccyx area. Observation showed the dressing change team were gowned and gloved in preparation to do the procedure. RN #1 prepared the work area while the assistant positioned 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.