Positive staff feedback, including praise for Ellie Jones and Emily Hymad
Cons
Limited clarity in admission, Medicaid, and financial-responsibility communication
Concerns about corporate management and organizational priorities
Summary of reviews
The reviews offer limited information about day-to-day care quality. One reviewer strongly praised the staff and specifically named Ellie Jones and Emily Hymad. Other comments expressed dissatisfaction with the organization, including one family member’s account of unclear financial-responsibility expectations during admission and difficulty resolving a Medicaid-related billing matter. That account raises concerns about how financial obligations and payment options are explained to families, but the reviews do not establish how consistently this issue occurs.
Feedback about management is mixed: one reviewer made a broad criticism of corporate leadership, while the other reviews provide little detail about management practices. The comments do not describe clinical services, staffing levels, or resident outcomes, so care quality cannot be assessed in depth. They also provide no information about dining, activities, or the condition and upkeep of the facilities.
Overall, the small set of reviews combines specific praise for two staff members with concerns about financial communication and corporate management. Families considering the center may wish to ask for clear written explanations of admission agreements, Medicaid-related expectations, and responsibility for outstanding charges, while seeking additional information about care, meals, activities, and facilities.
Reviews written on Mirador
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Medicare Ratings
5·/ 5
Overall
Health Inspection
Staffing
Quality Measures
Ratings from the U.S. Centers for Medicare & Medicaid Services (Care Compare). View on Medicare.gov
Location
Star Valley Care Center is located at 130 Hospital Ln, Afton, WY, 83110.
About Star Valley Care Center
Star Valley Care Center sits on Hospital Lane in Afton, Wyoming, right in Lincoln County, and the building has room for 24 residents, so the place never feels too crowded, and it seems the staff can give folks a lot of personal attention, which probably helps people feel like they're getting the care they need and aren't just a number, now there's always 24-hour supervision and help with things like bathing, dressing, and moving from one place to another, and if a person needs help with medication or diets for diabetes or special food needs, the team's got that covered too, and they also talk about offering mental wellness programs and tailored care plans so people's social, emotional, and spiritual needs get attention. There are memory care and assisted living services along with skilled nursing and short-term rehabilitation for people who need a bit more help after a hospital visit, plus there's independent living, respite care, and intermediate care for very fragile seniors, so it's a place that can handle different needs as time goes on, and families probably like that the same place can help as situations change. The community feels a bit like a small retirement community or care home and even pets have a place there, which not every center allows, and folks can fill out their application by phone or walk right in, which must make things easier for newcomers. For daily living, there's a furnished setting with TV, phone lines, and internet, so most people should find what they'd expect at home, and if someone wants to get their hair done, there's an in-house salon, too, along with meals served restaurant-style in a dining room, and meal prep makes sure each person gets what they need, especially for health reasons. Scheduled social activities, group outings, and an activities room help residents keep busy and talk with others, and the garden and outdoor spaces let folks get fresh air and walk around a bit, and there's a housekeeper to handle laundry and cleaning, so it should be easier to relax. When someone has a doctor's appointment, the staff can arrange transportation, and they've got access to a wide range of health care right on the main campus, whether that's physical therapy, pain management, sleep studies, or even seeing a specialist through Star Valley Health. The care team seems pretty involved, with nurses, social workers, activity staff, doctors, and administrators all pitching in, and there's an auxiliary and a Board of Trustees who help oversee things. Star Valley Care Center keeps a visitor policy, a place to share feedback, and ways for families to find extra resources, like the MyChart patient portal to help manage health information. The facility prides itself on providing services all the way from assisted living to more serious nursing care, plus ongoing rehab and therapy, and programs like diabetes education or CPR classes for anyone interested. Residents and families can look up a detailed map of the campus if they want to know where everything is, and there are regular updates to keep information as current as possible. The whole idea seems to be making life safe and comfortable for folks while still keeping things personal and treating each person as a whole individual, down to their physical, social, and spiritual needs.
People often ask...
Star Valley Care Center offers assisted living, memory care, and skilled nursing.
There are 3 photos of Star Valley Care Center on Mirador.
The full address for this community is 130 Hospital Ln, Afton, WY 83110.
No, Star Valley Care Center does not offer respite care.
Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.
Safety & Compliance
In Wyoming, the Department of Health's Healthcare Licensing & Surveys program licenses care facilities and publishes licensure, complaint, and life-safety findings.
License number
nh-181
Status
Open
Facility type
Nursing Home
Inspection Reports
100
Reports
17
Type A Citations
1
Type B Citations
14
Complaints
20
Years
13 May 2026Revisit
13 May 2026Revisit
Verified compliance with all regulations; earlier deficiencies were corrected.
28 Apr 2026Revisit
28 Apr 2026Revisit
Found no deficiencies after a Life Safety Code revisit; all prior issues were corrected and no new non-compliance identified.
12 Feb 2026Complaint
12 Feb 2026Complaint
Found deficiencies in safety during transfers, medication storage/expiration, and infection control practices. The findings showed potential risks to resident safety and quality of care.
§483.25(d)(1)(2)Free of Accident Hazards/Supervision/Devices
§483.45(g)(h)(1)(2)Label/Store Drugs and Biologicals
§483.80(a)(1)(2)(4)(e)(f)Infection Prevention & Control
12 Feb 2026Licensure
12 Feb 2026Licensure
Found no deficiencies. Compliance with state requirements observed.
10 Feb 2026Life Safety
10 Feb 2026Life Safety
Found that a gas-fired cooktop lacked the required restraint to protect flexible gas piping when moved, with the restraint disconnected.
NFPA 54, National Fuel Gas Code; NFPA 101, Life Safety CodeGas-fired equipment protection/restraint
05 Dec 2024Revisit
05 Dec 2024Revisit
Verified compliance with all requirements after addressing prior deficiencies.
09 Oct 2024Revisit
09 Oct 2024Revisit
Found no deficiencies.
17 Jul 2024Life Safety
17 Jul 2024Life Safety
Found noncompliance with emergency preparedness and life-safety requirements due to missing transfer arrangements and multiple fire-safety and electrical-system deficiencies.
42 CFR 483.73(b)(7)Arrangement with Other Facilities
NFPA 13, 2010 edition, Section 6.2.7.1Sprinkler System - Installation
NFPA 101, 2012 Edition, 19.3.2.5.3, 19.3.7.3, 8.5Subdivision of Building Spaces - Smoke Barrier Construction
NFPA 99, 2012 Edition, Sec. 6.4.4.1.2Electrical Systems - Other
11 Jul 2024Licensure
11 Jul 2024Licensure
Identified failure to offer pneumococcal vaccination according to CDC guidelines for one resident.
CFR 483.80(d)(1)-(2)Influenza and Pneumococcal Immunizations
29 Jun 2023Revisit
29 Jun 2023Revisit
Verified that previously identified life safety deficiencies were corrected and no new noncompliance was found.
26 Jun 2023Revisit
26 Jun 2023Revisit
Found no deficiencies and confirmed continued compliance.
11 May 2023Licensure
11 May 2023Licensure
Found that constipation care was not properly managed for a resident due to failure to follow the bowel protocol and administer PRN medications.
CFR 483.25Quality of Care
11 May 2023Licensure
11 May 2023Licensure
Concluded compliance with state requirements; no deficiencies were identified.
09 May 2023Life Safety
09 May 2023Life Safety
Found deficiencies in hazardous-area protection and in the annual testing of electrical main and feeder circuit breakers.
NFPA 101, 19.3.2.1.3Hazardous Areas - Enclosure
NFPA 99, Section 6.4.4.1.2Electrical Systems - Other
07 Sept 2022Revisit
07 Sept 2022Revisit
Verified that prior deficiencies were corrected and compliance was achieved.
26 Aug 2022Revisit
26 Aug 2022Revisit
Verified that all prior deficiencies were corrected and no new noncompliance was found.
23 Jun 2022Licensure
23 Jun 2022Licensure
Identified deficiencies in transfer and bed-hold notices, care plan updates, and wound care management. Findings showed noncompliance with multiple regulatory requirements across several care areas.
§483.15(c)(3)-(6)(8)Notice Requirements Before Transfer/Discharge
§483.15(d)(1)-(2)Notice of Bed Hold Policy Before/Upon Transfer
§483.21(b)(2)(i)-(iii)Care Plan Timing and Revision
§483.25Quality of Care
23 Jun 2022Life Safety
23 Jun 2022Life Safety
Identified deficiencies in emergency preparedness and life-safety systems, including failure to update the emergency plan annually, missing emergency contact information, and inadequate protection and maintenance of cooking facilities and fire safety systems.
§483.73(a)Emergency Plan—update annually
§483.73(c)(2)Emergency Officials Contact Information
NFPA 101; NFPA 70; NFPA 72Fire Alarm System - Testing and Maintenance
NFPA 101; NFPA 110; NFPA 111; NFPA 70Electrical Systems - Essential Electric System
23 Jun 2022Licensure
23 Jun 2022Licensure
Identified deficiencies in transfer/discharge notifications, bed-hold notices, care plan updates, and overall quality of care for multiple residents.
483.15(c)(3)-(6)(8)Notice Requirements Before Transfer/Discharge
483.15(d)(1)-(2)Notice of Bed-Hold Policy Before/Upon Transfer
483.21(b)(2)(i)-(iii)Care Plan Timing and Revision
483.25Quality of Care
09 Nov 2021Licensure
09 Nov 2021Licensure
Found no deficiencies related to infection control.
04 Aug 2021Revisit
04 Aug 2021Revisit
Determined that all prior deficiencies were corrected and no new noncompliance found.
30 Jun 2021Life Safety
30 Jun 2021Life Safety
Confirmed no deficiencies were found; all applicable requirements were met.
24 Jun 2021Licensure
24 Jun 2021Licensure
Identified deficiencies in accuracy of assessments, comprehensive care planning, constipation management, and infection prevention/control, including social distancing during meals for unvaccinated residents.
CFR 483.20(g)Accuracy of Assessments
CFR 483.21(b)(1)Develop/Implement Comprehensive Care Plan
CFR 483.25Quality of Care
CFR 483.80Infection Prevention & Control
24 Jun 2021Licensure
24 Jun 2021Licensure
Found no deficiencies.
27 May 2020Licensure
27 May 2020Licensure
Investigated a COVID-19 focused infection control survey and found no deficiencies.
23 Jul 2019Revisit
23 Jul 2019Revisit
Concluded compliance after a follow-up visit; all prior deficiencies were corrected and no new noncompliance was found.
01 Jul 2019Revisit
01 Jul 2019Revisit
Concluded that prior deficiencies were corrected and compliance was achieved.
02 May 2019Licensure
02 May 2019Licensure
Investigated a complaint and found deficiencies across resident rights, catheter care, bed rail safety, and medication management. The findings indicated several safety and dignity concerns.
§483.10(a)(1)-(a)(2); §483.10(b)(1)-(b)(2)Resident Rights/Exercise of Rights
§483.25(e)(1)-(e)(3)Bowel/Bladder Incontinence, Catheter, UTI
§483.25(n)(1)-(4)Bed Rails
§483.45(e)Free from Unnec Psychotropic Meds/PRN Use
§483.45(f)Free of Medication Error Rates 5 Percent or More
02 May 2019Licensure
02 May 2019Licensure
Found no deficiencies. The survey determined compliance with state requirements.
30 Apr 2019Life Safety
30 Apr 2019Life Safety
Identified a deficiency in maintaining electrical systems and testing as required; emergency preparedness was found to be in compliance.
NFPA 99, 2012 edition; 6.3.3.3.2; 6.3.4Electrical Systems - Maintenance and Testing
29 Jun 2018Revisit
29 Jun 2018Revisit
Verified that prior deficiencies were corrected and no new noncompliance was found.
15 Jun 2018Revisit
15 Jun 2018Revisit
Found no deficiencies. A follow-up visit confirmed compliance with all regulations surveyed.
25 May 2018Revisit
25 May 2018Revisit
Determined that the facility was in compliance with Federal requirements.
25 May 2018Revisit
25 May 2018Revisit
Determined the facility was in compliance with state requirements; found no deficiencies.
08 May 2018Complaint
08 May 2018Complaint
Determined that alleged abuse was not thoroughly investigated and residents were not adequately protected. Found deficiencies in how investigations were conducted and in safeguarding residents during the process.
Type A§483.12(c)(1)-(4)Investigation of Alleged Violations
Type A§483.12(c)(2)Investigation of Alleged Violations
30 Mar 2018Licensure
30 Mar 2018Licensure
Investigators identified multiple deficiencies in grievance procedures, transfer/discharge notices, resident care planning, and food safety practices. The findings show posted policies were missing, written processes were incomplete, and several required notices and records were not properly maintained.
§483.10(j)(3); §483.10(j)(4); §483.10(j)(2)Grievance procedures and information for residents
§483.15(c)(3)-(6); §483.15(c)(5)Notice requirements before transfer/discharge
§483.21(b)Comprehensive care plans
§483.60(i); §483.60(i)(2); §483.60(i)(3)Food service and handling requirements
§483.60(i)(1)(2)Food brought by visitors
§483.60(i)(3)Education on food handling
§483.24(a)(2)ADL care for residents with disabilities
30 Mar 2018Licensure
30 Mar 2018Licensure
Found hot water temperatures in resident sinks exceeded the limit, with readings around 112-113 F in several rooms.
Type ACh 11 Sec 6 (a)(iv)Physical Environment
28 Mar 2018Life Safety
28 Mar 2018Life Safety
Observed several life safety deficiencies in egress, hazardous areas, fire alarm testing, and exterior ramp conditions. Violations cited.
2012 NFPA 101 Section 8.3.3.1; 2010 NFPA 80 Section 5.2.1Means of Egress - General
2012 NFPA 101 Sections: 19.2.2.6; 3.3.219; 7.2.5.2.(2) (c)Ramps and Other Exits
2012 NFPA 101, Sections: 19.3.2; 8.7.1.3Hazardous Areas - Enclosure
2012 NFPA 101, Section: 9.6.1.3; 2010 NFPA 72, Section: 27.3.7.4.2Fire Alarm System - Testing and Maintenance
13 Apr 2017Revisit
13 Apr 2017Revisit
Determined the operation was brought back into compliance after follow-up surveys.
12 Apr 2017Revisit
12 Apr 2017Revisit
Concluded that the facility was brought back into compliance after follow-up surveys.
02 Mar 2017Life Safety
02 Mar 2017Life Safety
Identified deficiencies in life-safety and electrical systems, including sprinkler maintenance, corridor separation, and use of electrical equipment in patient-care areas.
2012 NFPA 101, Sections 19.2.10.1; 7.10.1.2.1; NFPA 25Sprinkler system maintenance and testing
2012 NFPA 101, Sections 9.7.5; 9.7.7; 9.7.8; 2011 NFPA 25, Section 5.3.2Corridors – areas open to corridors
NFPA 101 Life Safety CodeCorridor separation and maintenance
Identified multiple deficiencies in abuse reporting, pain management, infection control, hospice care, and resident-care practices requiring several corrective actions.
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24 Feb 2017Licensure
24 Feb 2017Licensure
Found no deficiencies. Determined compliance with State requirements.
09 May 2016Revisit
09 May 2016Revisit
Concluded that previously cited deficiencies were corrected.
483.13(c)(1)(ii)(iii), (c)(2)Resident rights
483.25Quality of care
483.35(1)Nursing services
18 Apr 2016Revisit
18 Apr 2016Revisit
Found no deficiencies.
10 Mar 2016Licensure
10 Mar 2016Licensure
Investigated an allegation and found deficiencies in staff background checks, pain management documentation, and food-safety procedures. The findings show failures to properly document abuse investigations, hire staff after verifying the nurse aide registry, adequately document PRN pain medications, and ensure sanitary handling of food.
—Abuse registry checks prior to hire and investigation reporting
—Continued From page 4 – pain management and medication administration
—FOOD PROCURE, STORE/PREPARE/SERVE – SANITARY
10 Mar 2016Licensure
10 Mar 2016Licensure
Found no deficiencies. The survey concluded the licensee was in compliance with state requirements.
08 Mar 2016Life Safety
08 Mar 2016Life Safety
Identified deficiencies in life-safety code compliance and generator maintenance documentation.
2000 NFPA 101 Life Safety Code (Sections 19.5.1 and 9.1.3); 1999 NFPA 110 (Section 6-4.1)Life Safety Code and generator maintenance
04 Jun 2015Revisit
04 Jun 2015Revisit
Investigated and cited life-safety deficiencies; some corrections were completed by 2015-04-12 and a follow-up revisit occurred on 2015-06-04.
Verified that deficiencies previously reported were corrected and a follow-up visit completed.
03 Jun 2015Revisit
03 Jun 2015Revisit
Investigated a complaint and confirmed that prior deficiencies were corrected; follow-up completed.
03 Mar 2015Life Safety
03 Mar 2015Life Safety
Investigated found a cross-connection due to an unapproved hose connection that disabled backflow prevention, indicating inadequate plumbing safeguards.
2006 IPC, Section 608.8 and 608.13Backflow prevention / cross-connection
03 Mar 2015Life Safety
03 Mar 2015Life Safety
Found that means of egress were obstructed by stored items; oxygen storage area contained drawers and plastic wrapping that blocked space.
1990 NFPA 101 Life Safety Code; Sections 19.2.1 and 7.1.10.1; NFPA 99Means of egress free of obstructions
03 Mar 2015Life Safety
03 Mar 2015Life Safety
Investigated a deficiency related to obstructions in corridors; wheelchairs and patient lifts were stored in corridors, creating potential egress issues.
NFPA 101 Life Safety Code Standard (2000 edition), Sections 19.2.1 and 7.1.10.1; NFPA 99Means of egress obstructions and storage in corridors
26 Feb 2015Complaint
26 Feb 2015Complaint
Investigated a complaint and found deficiencies in meal service, including snacks at bedtime, as well as deficiencies in infection control practices.
Type A—Food service deficiencies
Type A—Meal service scheduling and snacks
—Infection control program
26 Feb 2015Complaint
26 Feb 2015Complaint
Investigated a complaint and found multiple deficiencies in meal service and infection control.
Type A—Continued From page 3 - dietary service
Type A—Continued From page 4 - snacks
Type A—Continued From page 6 - spread, linens
Type B—Continued From page 6 - infection control program
c—Continued From page 6 - hand hygiene
26 Feb 2015Licensure
26 Feb 2015Licensure
Concluded that there were no deficiencies and the provider was in compliance with state requirements.
28 Aug 2014Revisit
28 Aug 2014Revisit
Investigated follow-up on prior life-safety deficiencies; corrective actions were completed for several items.
NFPA 101 / Life Safety CodeLife Safety Code deficiency
NFPA 101 / Life Safety CodeLife Safety Code deficiency
NFPA 101 / Life Safety CodeLife Safety Code deficiency
NFPA 101 / Life Safety CodeLife Safety Code deficiency
NFPA 101 / Life Safety CodeLife Safety Code deficiency
NFPA 101 / Life Safety CodeLife Safety Code deficiency
NFPA 101 / Life Safety CodeLife Safety Code deficiency
NFPA 101 / Life Safety CodeLife Safety Code deficiency
NFPA 101 / Life Safety CodeLife Safety Code deficiency
28 Aug 2014Revisit
28 Aug 2014Revisit
Verified that previous deficiencies were corrected and follow-up actions completed.
19 Jun 2014Revisit
19 Jun 2014Revisit
Investigated a post-certification revisit to verify prior survey findings and confirm follow-up actions; the revisit was conducted on 2014-06-19.
17 Apr 2014Licensure
17 Apr 2014Licensure
Identified deficiencies in medication management including narcotics handling and drug records, and in food service sanitation.
Comprehensive Drug Abuse Prevention and Control Act of 1976Drug records and narcotics handling
17 Apr 2014Licensure
17 Apr 2014Licensure
Found no deficiencies.
16 Apr 2014Life Safety
16 Apr 2014Life Safety
Investigated safety concerns in the building and found several life-safety deficiencies, including lack of emergency lighting, inadequate documentation of fire drills, and issues with sprinkler and electrical system coverage.
NFPA 101 Life Safety Code StandardEmergency lighting; door closer
NFPA 101 Life Safety Code StandardFire drills documentation (second shift)
NFPA 101 Life Safety Code StandardSprinkler coverage; electrical/mechanical modifications
16 Apr 2014Life Safety
16 Apr 2014Life Safety
Investigated a deficiency regarding improper drainage and plumbing for an ice machine, including missing air gap and non-code components.
2006 IPC, Section 411; WDH Chapter 3 GuidelinesIce machine drainage not installed to code; lacks indirect drain and air gap
15 Aug 2013Licensure
15 Aug 2013Licensure
Investigation identified multiple deficiencies related to resident care documentation, monitoring of conditions, and staffing/planning processes.
Type A—Continued from page 2: Resident condition monitoring and notification
Type A—Continued from page 3: Repeated observation of resident’s condition
Type A—Continued from page 4: Documentation and care plan deficiencies
Type A—Continued from page 18/19: Nursing documentation and transfers
Type A—Posting of staffing data and oversight
Type A—Continued from page 29: Staffing/safety postings
17 Jul 2013Licensure
17 Jul 2013Licensure
Investigated a deficiency in medication management; found insulin vials left open without labeled opened dates.
—Provision of pharmacy services
17 Jul 2013Licensure
17 Jul 2013Licensure
Found no deficiencies. The provider was in compliance with state requirements.
17 Jul 2013Licensure
17 Jul 2013Licensure
Investigated a complaint and confirmed the provider was in compliance with state requirements.
16 Jul 2013Life Safety
16 Jul 2013Life Safety
An inspection identified life-safety deficiencies, including incomplete sprinkler coverage and malfunctioning emergency lighting, with required corrective actions noted.
NFPA 101 Life Safety Code StandardEmergency lighting not functioning
NFPA 101 Life Safety Code StandardSprinkler coverage deficient
16 Jul 2013Life Safety
16 Jul 2013Life Safety
Identified multiple life-safety deficiencies related to fire protection and emergency systems, including sprinkler coverage and backup power/lighting.
NFPA 101 LIFE SAFETY CODE STANDARDEmergency lighting / power redundancy
NFPA 101 LIFE SAFETY CODE STANDARDGenerator / emergency power testing
NFPA 101 LIFE SAFETY CODE STANDARDAdditional life-safety controls and egress measures
07 Feb 2013Revisit
07 Feb 2013Revisit
Found no deficiencies during the follow-up visit after the prior survey.
28 Dec 2012Complaint
28 Dec 2012Complaint
Investigated and found a deficiency for failing to thoroughly investigate one of two abuse allegations in a timely manner.
—Investigations of alleged abuse must be thorough and timely
21 Sept 2012Revisit
21 Sept 2012Revisit
Verified that previously cited deficiencies were corrected.
27 Aug 2012Revisit
27 Aug 2012Revisit
Corrected Life Safety Code deficiencies identified during the revisit; all corrections completed.
NFPA 101 Life Safety CodeLife Safety Code deficiency
NFPA 101 Life Safety CodeLife Safety Code deficiency
NFPA 101 Life Safety CodeLife Safety Code deficiency
11 Jul 2012Complaint
11 Jul 2012Complaint
Investigated a nursing care setting and found deficiencies in medical record coding, nursing coverage, and medication management.
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11 Jul 2012Licensure
11 Jul 2012Licensure
Determined that the operation was in compliance with state requirements following a survey conducted July 9-11, 2012.
10 Jul 2012Life Safety
10 Jul 2012Life Safety
Identified multiple life-safety deficiencies, including unsealed conduit penetrations, incomplete fire safety system requirements, and missing documentation related to fire alarm certification.
NFPA 72, Life Safety Code Standard (Central Station) – 1999/2000 EditionCentral station certificate posting
NFPA 101 Life Safety Code StandardOne-hour fire-rated construction; sealed conduits
—Unsealed conduit penetrations (kitchen ceiling)
—Fire alarm system testing frequency
04 Aug 2011Revisit
04 Aug 2011Revisit
Found Life Safety Code deficiencies; corrections completed.
483.20(g)-(i)Life Safety Code 483.20(g)-(i)
483.70(h)Life Safety Code 483.70(h)
483.75(b)Life Safety Code 483.75(b)
04 Aug 2011Revisit
04 Aug 2011Revisit
Investigated prior deficiencies and confirmed they were corrected.
14 Jul 2011Revisit
14 Jul 2011Revisit
Verified that prior deficiencies were corrected and compliance was achieved.
27 May 2011Revisit
27 May 2011Revisit
Identified Life Safety Code deficiencies during a revisit, with three cited violations.
NFPA 101, Life Safety Code (LSC)Life Safety Code deficiency
NFPA 101, Life Safety Code (LSC)Life Safety Code deficiency
NFPA 101, Life Safety Code (LSC)Life Safety Code deficiency
26 May 2011Life Safety
26 May 2011Life Safety
Found deficiencies in life-safety measures including corridor door smoke resistance, electrical wiring not in compliance with code, and inadequate maintenance of cooking facilities.
NFPA 101 Life Safety Code StandardCorridor doors must resist the passage of smoke
NFPA 101 Life Safety Code Standard; NFPA 70 National Electrical CodeElectrical wiring and equipment not in compliance with NEC
NFPA 101 Life Safety Code Standard; NFPA 96Cooking facilities maintained
26 May 2011Licensure
26 May 2011Licensure
Investigated; identified deficiencies in administration due to the lack of a full-time on-site administrator.
—LIC REGS FOR NURSING HOMES
26 May 2011Complaint
26 May 2011Complaint
Investigated deficiencies found in MDS assessment signing and CNA training reimbursements, with corrective actions noted. Observed issues related to staff training documentation and facility environmental safeguards.
Type A—RN must sign MDS assessment (Section Z0500)
Type A—CNA training reimbursement not provided
Type A—Facility must provide a safe environment (environmental/safety improvements)
26 May 2011Revisit
26 May 2011Revisit
Found no deficiencies. No violations were cited during the follow-up assessment.
13 May 2011Licensure
13 May 2011Licensure
Investigated deficiencies in medication management and documentation, including order recapitulation and gradual dose reduction processes.
—Continued from page 1
—Continued from page 2/3
21 Jul 2010Revisit
21 Jul 2010Revisit
Identified deficiencies related to quality of care and administration.
483.20(k)(3)(i)Quality of care
483.60(c)Administration
19 Jul 2010Revisit
19 Jul 2010Revisit
Found no deficiencies during the follow-up visit.
13 May 2010Life Safety
13 May 2010Life Safety
Observed several life-safety deficiencies: one smoke barrier door lacked a self-closing device, a sprinkler head wrench handle was missing, alcohol-based hand rub dispensers were placed over ignition sources, and generator test logs were not maintained.
NFPA 101 Life Safety Code StandardSmoke barrier door self-closer device missing
NFPA 101 Life Safety Code StandardSprinkler head wrench handle missing
NFPA 101 Life Safety Code StandardAlcohol-based hand rub dispensers over ignition sources
NFPA 101 Life Safety Code StandardGenerator test documentation lacking
13 May 2010Licensure
13 May 2010Licensure
Found no deficiencies identified after a recertification survey conducted May 11-13, 2010.
18 Aug 2009Revisit
18 Aug 2009Revisit
Found substantial compliance after revisiting; corrections for prior deficiencies were completed.
25 Jun 2009Licensure
25 Jun 2009Licensure
Identified deficiencies in housekeeping and maintenance due to damaged flooring in bathing areas, creating unsanitary conditions and potential harborage for bacteria.
—Housekeeping/Maintenance
06 May 2009Licensure
06 May 2009Licensure
Found no deficiencies. Determined substantial compliance with participation requirements.
06 May 2009Licensure
06 May 2009Licensure
Determined that no deficiencies were identified and the licensure status showed substantial compliance with state rules and regulations.
05 May 2009Life Safety
05 May 2009Life Safety
Investigated and found no deficiencies related to the Life Safety Code. Building had full sprinkler coverage and an addressable fire alarm system.
27 Apr 2006Revisit
27 Apr 2006Revisit
Investigated deficiencies from a prior CMS-2567; all cited items were corrected during the follow-up visit and actions completed.
483.15(h)(2)
483.20, 483.20(b)
483.20(g) - (i)
483.35(h)(2)
483.70(c)(2)
483.70(h)
31 Mar 2006Revisit
31 Mar 2006Revisit
Verified the required corrections for life-safety/code deficiencies were completed after a follow-up visit.
NFPA 101 Life Safety CodeID Prefix
NFPA 101 Life Safety CodeReg. #
NFPA 101 Life Safety CodeReg. #
NFPA 101 Life Safety CodeReg. #
23 Feb 2006Licensure
23 Feb 2006Licensure
Identified deficiencies in housekeeping/maintenance, resident assessment accuracy, and sanitary conditions of food preparation and service.
483.15(h)(2)HOUSEKEEPING/MAINTENANCE
483.20(g)-(j)RESIDENT ASSESSMENT
483.35(h)(2)SANITARY CONDITIONS - FOOD PREP & SERVICE
483.70(c)(2)SPACE AND EQUIPMENT
07 Feb 2006Life Safety
07 Feb 2006Life Safety
Found deficiencies related to obstructed egress, overdue fire-extinguisher maintenance, and unsafe electrical receptacles.
NFPA 101 Life Safety Code, sections 19.7.1.2 and 7.1.10.1Means of egress unobstructed
NFPA 101 Life Safety Code; NFPA 10Portable fire extinguishers
NFPA 70 National Electrical Code; NFPA 70 Sections 400-8 and 110-27Electrical system installation
07 Feb 2006Life Safety
07 Feb 2006Life Safety
Investigated found life-safety deficiencies including obstructed means of egress, damaged electrical cords, and failures related to electrical wiring and fire safety equipment.
NFPA 101 Life Safety Code; NFPA 101 19.7.1.2; 7.1.10.1Means of egress obstructed
NFPA 10Portable fire extinguishers not tested
NFPA 70 (Electrical wiring); NFPA 70 Section 4.4.3Electrical system not installed per NFPA 70
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