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Medicare Ratings
1·/ 5
Cited by CMS for abuse, or potential for abuse, on its most recent survey cycle.
Overall
Health Inspection
Staffing
Quality Measures
Ratings from the U.S. Centers for Medicare & Medicaid Services (Care Compare). View on Medicare.gov
Location
Wyoming Retirement Center is located at 890 Highway 20 So, Basin, WY, 82410.
About Wyoming Retirement Center
Wyoming Retirement Center sits in a scenic area and has 90 beds, offering several types of care so people can live the way they need to, and there's communities for assisted living, memory care, independent living, skilled nursing, respite care, and home care, all in the same place. Residents get help with things like bathing, dressing, medication management, meals, and moving around, and there's 24-hour staff and a call system for safety and peace of mind. Memory care services focus on seniors with Alzheimer's or dementia, with special housing and safety features to cut down on confusion or wandering, while assisted living helps with daily tasks but still keeps people active and social, and independent living brings a simple, low-maintenance lifestyle with chances to enjoy company and activities. The center has a mix of studio and two-bedroom rooms, each with private bathrooms, air conditioning, cable TV, Wi-Fi, kitchenettes, and furnishings, and everything's built so seniors with limited mobility can get around easily, whether they're in their own rooms or using the shared spaces.
Amenities cover most things older adults want, like transportation, parking, a pet-friendly policy, beauty salon, computer center, dining room with restaurant-style and all-day meals, fitness and wellness centers, game and activity rooms, movie theater, small library, garden, and walking paths, and the kitchen can tailor meals for diabetic or special diets with help from professional chefs. There are lots of scheduled and resident-run activities, group events, day trips, arts, music programs, and movie nights, all meant to keep people busy and social. The staff is trained to keep seniors safe, well, and respected, with medical support and personalized care plans, including skilled nursing care for people recovering after a hospital stay, illness, or surgery. Housekeeping, laundry and dry cleaning, move-in coordination, and support for residents' families are part of life here, and the community accepts both Medicaid and Medicare. Wyoming Retirement Center, run by Mary Ann Morse Healthcare Corp., has a 2-star Medicare rating for its nursing home and an average rating of 8.4 out of 10, which is the highest in the city, so while it covers many needs and comforts, what people get is a place where support and independence go together, with help available when it's needed, and enough to do so life doesn't slow down.
People often ask...
Wyoming Retirement Center offers independent living, assisted living, and skilled nursing.
The full address for this community is 890 Highway 20 So, Basin, WY 82410.
No, Wyoming Retirement 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-183
Facility type
Nursing Home
Inspection Reports
113
Reports
26
Type A Citations
1
Type B Citations
41
Complaints
21
Years
19 Feb 2025Complaint
19 Feb 2025Complaint
Found no deficiencies after reviewing the complaint investigations.
12 Dec 2024Complaint
12 Dec 2024Complaint
Identified multiple instances of abuse and neglect with ongoing safety concerns for residents. The finding notes failures to protect residents and properly address investigations and reporting.
§483.12Freedom from Abuse, Neglect, and Exploitation
12 Dec 2024Life Safety
12 Dec 2024Life Safety
Determined deficiencies in emergency volunteers policy and hazardous area enclosure protection.
Type A42 CFR 483.73(b)(6)Policies/Procedures - Volunteers and Staffing
Type ANFPA 101 Life Safety Code, 19.7.1.6Hazardous Areas - Enclosure Area
23 May 2024Complaint
23 May 2024Complaint
Investigated a resident-to-resident abuse issue and found the facility failed to ensure residents were free from abuse by other residents.
§483.12Freedom from Abuse, Neglect, and Exploitation
10 Apr 2024Complaint
10 Apr 2024Complaint
Investigated a complaint and determined that no deficiencies were identified.
21 Feb 2024Revisit
21 Feb 2024Revisit
Found no deficiencies. A follow-up visit showed full compliance with all regulations.
10 Jan 2024Revisit
10 Jan 2024Revisit
Verified no deficiencies were identified and all prior deficiencies have been corrected.
28 Dec 2023Complaint
28 Dec 2023Complaint
Investigated a resident-to-resident abuse case and found violations of resident rights due to inadequate protections against abuse.
483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
05 Dec 2023Revisit
05 Dec 2023Revisit
Verified previously identified deficiencies were corrected and no new noncompliance was found.
28 Sept 2023Complaint
28 Sept 2023Complaint
Investigated deficiencies related to the accuracy of assessments and the management of residents’ nutrition and medications. Found issues with documentation, weight monitoring, and unnecessary use of psychotropic PRN medications.
§483.25(g)(1)Accuracy of Assessments
§483.25(g)(2)Nutrition/Hydration Status Maintenance
§483.45(e)(1)-(5)Free from Unnecessary Psychotropic Meds/PRN Use
28 Sept 2023Licensure
28 Sept 2023Licensure
Determined to be in compliance with state requirements after the survey.
26 Sept 2023Life Safety
26 Sept 2023Life Safety
Investigated deficiencies found in emergency preparedness planning, including failure to annually review/update the emergency plan, insufficient communication methods, and inadequate testing of the plan.
483.73(a)Emergency planning and preparedness - annual review
483.73(c)(3)Primary and alternate means for communication
483.73(d)(2)Emergency preparedness testing
16 Mar 2023Revisit
16 Mar 2023Revisit
Concluded that all prior deficiencies were corrected and no new noncompliance was found.
15 Feb 2023Complaint
15 Feb 2023Complaint
Investigated a complaint and identified deficiencies related to resident safety and staff conduct.
§483.12(a)Freedom from Abuse, Neglect, and Exploitation
08 Dec 2022Complaint
08 Dec 2022Complaint
Identified no deficiencies after a complaint survey conducted from 12/07/22 to 12/08/22.
06 Dec 2022Revisit
06 Dec 2022Revisit
Concluded that all deficiencies were corrected and no new noncompliance was found.
28 Oct 2022Revisit
28 Oct 2022Revisit
Verified no deficiencies found; all previously cited issues were corrected.
14 Jul 2022Licensure
14 Jul 2022Licensure
Investigated found multiple deficiencies in care planning, safety practices, and infection control with required follow-up actions.
483.25Quality of Care
483.25(d)(1)(2)Free of Accident Hazards/Supervision/Devices
483.80Infection Prevention & Control
483.21(c)(2)Discharge Summary
12 Jul 2022Life Safety
12 Jul 2022Life Safety
Identified deficiencies in fire safety and kitchen equipment placement, indicating noncompliance with federal life-safety requirements and NFPA standards.
NFPA 101 Life Safety Code; NFPA 101 19.3.2.5.1; 9.2.3; NFPA 96 12.1.2.3Continued From page 3
04 May 2022Complaint
04 May 2022Complaint
Found no deficiencies identified during the complaint investigation or vaccination review.
10 Nov 2021Complaint
10 Nov 2021Complaint
Determined that no deficiencies were identified in the complaint-based review and the COVID-19 focused infection control review.
01 Oct 2021Complaint
01 Oct 2021Complaint
Found no deficiencies identified after review of the complaint investigation and infection control assessment.
01 Sept 2021Complaint
01 Sept 2021Complaint
Found no deficiencies identified during the complaint investigation and COVID-19 focused infection control survey.
15 Jul 2021Revisit
15 Jul 2021Revisit
Concluded there were no deficiencies; prior deficiencies corrected.
15 Jul 2021Revisit
15 Jul 2021Revisit
Verified all previously cited deficiencies were corrected; no new noncompliance found.
29 Jun 2021Revisit
29 Jun 2021Revisit
Verified that all deficiencies identified in the earlier survey were corrected and compliance restored.
—Initial Comments
—Initial Comments
06 May 2021Complaint
06 May 2021Complaint
Investigated deficiencies found in inaccurate resident assessments, expired medications, improper dietary staff qualifications, and unsafe food storage/cooling practices.
CFR 483.20(g)Accuracy of Assessments
CFR 483.45Pharmacy Services
CFR 483.60Qualified Dietary Staff
CFR 483.60(i)Food Safety Requirements
06 May 2021Licensure
06 May 2021Licensure
Identified that the dietary manager did not hold the required certification and was enrolled in a training program; a kitchen staff member had completed a course but was not in an active manager role.
Ch 11 Sec 11 (a)(i)Dietary Services
05 May 2021Life Safety
05 May 2021Life Safety
Found deficiencies in emergency preparedness training/testing and in means of egress maintenance. In particular, training policy was missing and exterior egress doors did not meet egress requirements.
42 CFR 483.73(d)Emergency Preparedness Training and Testing
NFPA 101, 19.2.2.2.4(3); 7.2.1.6.2; 7.2.1.6.1.1(3)Means of Egress - General
07 Jan 2021Revisit
07 Jan 2021Revisit
Confirmed that all previously cited deficiencies were corrected and no new noncompliance was found.
19 Nov 2020Complaint
19 Nov 2020Complaint
Identified no deficiencies during the complaint investigation and the COVID-19 focused infection survey.
02 Oct 2020Complaint
02 Oct 2020Complaint
Investigated allegations of verbal abuse toward a resident. Found that staff used profanity toward a resident during care, violating abuse policy.
CFR 483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
12 May 2020Licensure
12 May 2020Licensure
Found no deficiencies related to infection control.
20 Aug 2019Complaint
20 Aug 2019Complaint
Investigated two complaints and found no deficiencies.
15 Aug 2019Revisit
15 Aug 2019Revisit
Verified that prior deficiencies were corrected and no new noncompliance was found.
15 Aug 2019Revisit
15 Aug 2019Revisit
Verified that all previously cited deficiencies were corrected and that no new noncompliance was found.
31 Jul 2019Revisit
31 Jul 2019Revisit
Verified all prior deficiencies were corrected and no new noncompliance was found.
13 Jun 2019Licensure
13 Jun 2019Licensure
Inspector findings showed deficiencies in MDS assessments and care planning, cross-referencing corrective actions, and infection control including antibiotic use and monitoring.
§483.21(b)(2)(i)-(iii)MDS/Comprehensive Care Plans
§483.21(b)Provider's Plan of Correction / Care Plan Cross-References
§483.45(a)(2)ADL/Care and Antibiotic Stewardship
§483.80(a)(3)Infection Prevention and Control / Antibiotic Stewardship
13 Jun 2019Licensure
13 Jun 2019Licensure
Concluded that the facility was in compliance with State requirements.
12 Jun 2019Life Safety
12 Jun 2019Life Safety
Identified multiple life-safety deficiencies involving hazardous areas enclosure, cooking facilities, smoke barrier integrity, and elevator compliance.
NFPA 101 (2012) 19.3.2.1; 19.3.5.9Hazardous Areas - Enclosure
NFPA 101 (2012)Cooking Facilities
NFPA 101 (2012) 19.3.*; 8.6.*; 9.4.*Penetrations in fully ducted HVAC systems and smoke barrier integrity
NFPA 101 (2012) 19.5.3; 9.4.2; 9.4.3Elevators
24 May 2019Complaint
24 May 2019Complaint
Investigated an alleged abuse incident and found concerns about the investigation's thoroughness and documentation.
Type A§483.12(c)(2)-(4)Investigation, notification, and response to suspected abuse/neglect
09 Apr 2019Complaint
09 Apr 2019Complaint
Found no deficiencies after investigating a complaint.
04 Dec 2018Revisit
04 Dec 2018Revisit
Verified no deficiencies were found on the follow-up assessment.
08 Nov 2018Revisit
08 Nov 2018Revisit
Investigated anticoagulant management and found failures in monitoring and dosing for residents on Coumadin, including delays in INR checks and unresolved conflicting orders.
42 CFR 483.25Quality of care
20 Sept 2018Complaint
20 Sept 2018Complaint
Investigated a complaint and found deficiencies in monitoring anticoagulant therapy, fall prevention, and pain management, including adverse outcomes and a resident death related to excessive INR.
CFR 483.25Quality of care
CFR 483.25(d)Accidents
CFR 483.25(k)Pain Management
16 Jul 2018Revisit
16 Jul 2018Revisit
Concluded that all previous deficiencies were corrected and no new noncompliance was found.
10 Jul 2018Complaint
10 Jul 2018Complaint
Investigated the complaint and found no deficiencies identified.
05 Jul 2018Revisit
05 Jul 2018Revisit
Investigated emergency preparedness deficiencies; corrected all issues and found no new noncompliance.
—Emergency Preparedness – initial deficiency
CRR(s): 483.73(b)Development of EP Policies and Procedures
05 Jul 2018Revisit
05 Jul 2018Revisit
Observed compliance; all previous deficiencies were corrected and no new noncompliance was found.
26 Apr 2018Licensure
26 Apr 2018Licensure
Investigated deficiencies in bed-hold policy, transfer/discharge notices, medication management, and sanitation. Findings showed gaps in discharge planning and related record-keeping.
§483.15(c)(5)Bed-hold policy
§483.70(1)Transfer/discharge planning
§483.70(1)Transfer/discharge planning
§483.45 Pharmacy ServicesPharmacy services
§483.45 Pharmacy ServicesPharmacy services
§483.60 Food Safety RequirementsSanitation and safety of equipment and surfaces
26 Apr 2018Licensure
26 Apr 2018Licensure
Found no deficiencies.
25 Apr 2018Life Safety
25 Apr 2018Life Safety
Identified several deficiencies including restricted egress due to a padlocked courtyard gate, improper storage of combustibles, unsafe electrical cords, and gaps in emergency preparedness planning and coordination.
—Padlock on courtyard gates restricting egress
—Hazardous Areas - Enclosure
—Electrical Equipment - Power Cords and Extension Cords
CFR(s): 483.73(a)(4)Local, State, Tribal Collaboration Process
CFR(s): 483.73(b)Development of EP Policies and Procedures
CFR(s): 483.73(c)Development of Communication Plan
06 Sept 2017Revisit
06 Sept 2017Revisit
Verified compliance after a follow-up visit; all prior deficiencies were corrected and no new noncompliance was found.
08 Aug 2017Revisit
08 Aug 2017Revisit
Found life-safety code deficiencies; all cited items were corrected during the follow-up.
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
20 Jul 2017Revisit
20 Jul 2017Revisit
Investigated deficiencies related to code status documentation and emergency response; staff needed to improve process for identifying full-code residents.
Type A—Code status documentation and communication
17 May 2017Life Safety
17 May 2017Life Safety
Identified multiple life-safety deficiencies, including exit doors that could not be opened without a key, inadequate ramp/handrail provisions, missing sprinkler coverage, and staff unawareness of certain NFPA requirements.
NFPA 101 Life Safety Code 2012, 18.2.2.4; 19.2.2.2.4Maintaining means of egress; exit doors must be readily operable
NFPA 101 Life Safety Code 2012, sections 19.2.2.2.4; 3.3.2; 7.2.5.2(2)(c)Ramp and handrail not provided to code
NFPA 101 Life Safety Code 2012, Sections 19.3.2.1; 9.7.1; NFPA 13 210-8(a)(6)Sprinkler system not installed in required areas
NFPA 101 Life Safety Code 2012, Sections 9.1.2; NFPA 70, Section 210-8(a)(6)Utilities – Gas and Electric; staff unaware of the requirement
11 May 2017Licensure
11 May 2017Licensure
Determined that the facility was in compliance with State requirements. No deficiencies were cited.
11 May 2017Complaint
11 May 2017Complaint
Investigated a complaint and found deficiencies related to resident rights, safety measures, and documentation; corrective actions were identified.
15 Feb 2017Complaint
15 Feb 2017Complaint
Found no deficiencies identified during the complaint survey conducted Feb 14-15, 2017.
16 Jun 2016Revisit
16 Jun 2016Revisit
Verified the previously cited deficiencies were corrected.
483.40(c)(1)-(2)
483.45(b)
483.75(l)(1)
03 Jun 2016Revisit
03 Jun 2016Revisit
Investigated a licensing revisit and found no deficiencies.
31 Mar 2016Licensure
31 Mar 2016Licensure
Investigated deficiencies found in hydration, medication administration, physician visit timeliness, therapy services, infection control, and quality assurance processes.
483.12(a)Notification of changes in condition
483.25(i)Sufficient Fluid to Maintain Hydration
483.40(c)(1)-(2)Frequency and Timeliness of Physician Visits
483.75(b)Rehabilitation Services – Physician Orders/Qualified Person
483.65Infection Control
483.75Quality Assurance and Performance Improvement (QAPI)
483.75Quality Assurance and Performance Improvement (QAPI)
31 Mar 2016Licensure
31 Mar 2016Licensure
Investigated a complaint intake and conducted a recertification survey; found no deficiencies.
29 Mar 2016Life Safety
29 Mar 2016Life Safety
Investigated generator maintenance; weekly inspections were not documented.
Verified that previously reported deficiencies were corrected and actions completed; no new deficiencies identified.
02 Apr 2015Revisit
02 Apr 2015Revisit
Identified life-safety code deficiencies that were subsequently corrected.
NFPA 101 Life Safety CodeLife Safety Code deficiency
NFPA 101 Life Safety CodeLife Safety Code deficiency
NFPA 101 Life Safety CodeLife Safety Code deficiency
02 Apr 2015Revisit
02 Apr 2015Revisit
Investigated the complaint and identified deficiencies cited during the revisit.
20 Mar 2015Revisit
20 Mar 2015Revisit
Investigated a follow-up on earlier deficiencies and found that all required corrections were completed.
17 Mar 2015Revisit
17 Mar 2015Revisit
Investigated the follow-up and confirmed that previously identified deficiencies were corrected.
24 Feb 2015Life Safety
24 Feb 2015Life Safety
An inspection identified multiple life-safety and maintenance deficiencies, including issues with exit marking, egress doors, emergency lighting, and fire safety policies. Several items required corrective actions and ongoing monitoring.
Type ANFPA 101 Life Safety Code Standard; 2000 NFPA 101 Section 19.2.1, 7.2.1.4Exit access/egress markings
Type ANFPA 101 Life Safety Code Standard; 2000 NFPA 101 Section 19.x (as cited in the report)Door height/placement
Type ANFPA 101 Life Safety Code Standard; Sections 19.x and related emergency lighting requirements (as cited)Emergency lighting policy/requirements
Type ANFPA 101 Life Safety Code Standard; 2000 NFPA 101 Section 19.7.1.1 (as cited)Facility fire/safety policy
Type ANFPA 101 Life Safety Code Standard; referencing NFPA sections (as cited)Ceiling tile/areas requiring updates
Type ANFPA 101 Life Safety Code Standard; 19.7.5.1 and NFPA 13 (as cited)Curtains/draperies and furnishings
29 Jan 2015Licensure
29 Jan 2015Licensure
Investigated found two deficiencies: water temperatures exceeded 110°F in nursing areas and dietetic services lacked a certified dietary manager with proper supervision.
Type ACh 11 Sec 6 (a)(iv) Physical EnvironmentPhysical Environment
Type ACh 11 Sec 11 (a)(i) Dietetic ServicesDietetic Services
29 Jan 2015Complaint
29 Jan 2015Complaint
Investigated a complaint and found multiple deficiencies related to privacy, resident dignity during meals, and adherence to care plans by staff; corrective actions were outlined.
—Privacy/Confidentiality of Records
—Dignity and Respect of Residents
—Dietary/Nutrition Services
—Nursing Services
—Nursing Administration
28 Jan 2015Life Safety
28 Jan 2015Life Safety
Found deficiencies in medical gas storage and electrical safety, including missing door closer and NFPA 99 signage deficiencies.
NFPA 99Medical gas storage area signage
NFPA 99Medical gas storage signage adequacy
NFPA 70Electrical wiring
06 Mar 2014Licensure
06 Mar 2014Licensure
Investigated a complaint and found no deficiencies.
05 Dec 2013Licensure
05 Dec 2013Licensure
Identified deficiency in dietetic services due to lack of enrollment of the dietetic manager in the required course; a plan to enroll and complete training was provided.
Ch 11 Sec 11(a)(1)Dietetic Services
05 Dec 2013Licensure
05 Dec 2013Licensure
Identified deficiencies in resident care and safety during the survey, including inadequate toileting assistance, grooming, and monitoring.
03 Dec 2013Life Safety
03 Dec 2013Life Safety
The inspection identified multiple life-safety and facility management deficiencies, including unsafe door conditions, sprinkler system issues, and inadequate policy implementation. Numerous items required corrective actions and ongoing monitoring.
NFPA 101 Life Safety CodeContinued From page 2
NFPA 101 Life Safety CodeContinued From page 3
NFPA 101 Life Safety CodeContinued From page 4
NFPA 101 Life Safety CodeFacility Policy
NFPA 101 Life Safety CodeContinued From page 7
NFPA 101 Life Safety CodeContinued From page 11
NFPA 101 Life Safety CodeContinued From page 13
NFPA 101 Life Safety CodeContinued From page 12
20 Aug 2013Complaint
20 Aug 2013Complaint
Identified a deficiency due to the lack of written physician orders for residents at the time of admission.
—Admission Physician Orders for Immediate Care
22 May 2013Revisit
22 May 2013Revisit
Investigated follow-up on prior deficiencies. Found no deficiencies.
14 Mar 2013Complaint
14 Mar 2013Complaint
Found that residents requiring extensive daily-living assistance did not receive adequate bathing and personal hygiene support.
F 312Continued From page 2
F 353Continued From page 3
04 Oct 2012Complaint
04 Oct 2012Complaint
An inspection identified multiple deficiencies in resident rights, care practices, infection control, and staff training, with several items continuing across pages. The findings show inadequate policies, documentation gaps, and insufficient monitoring of compliance.
—Resident rights; correction of deficiencies
—Summary of deficiencies; resident rights/ care standards
—Preventive/clinical care and safety measures
—Environmental conditions; safety and sanitation
—Staff training and procedural adherence
02 Oct 2012Life Safety
02 Oct 2012Life Safety
Identified several fire-safety deficiencies, including issues with drills, smoke barrier integrity, door operations, and record-keeping.
—INITIAL COMMENTS
—DOORS AND FIRE BARRIERS
—SMOKE BARRIER WALLS
—RECORDS / STAFF AWARENESS
—Continued From page 7
10 Nov 2011Revisit
10 Nov 2011Revisit
Identified several life-safety-code deficiencies with corrective actions completed.
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
09 Nov 2011Revisit
09 Nov 2011Revisit
Identified deficiencies requiring correction; all corrections completed by the revisit.
483.20(g)-(i)Residents' Rights
483.20(k)(3)(ii)Residents' Rights
483.20(d)Residents' Rights
483.25(h)Quality of Care and Safety
483.25(a)(2)Quality of Care and Safety
483.25(d)Quality of Care and Safety
483.75(l)(3)Quality of Care and Safety
25 Aug 2011Licensure
25 Aug 2011Licensure
Investigated deficiencies in record-keeping and resident-care processes, including inaccurate MDS assessments, incomplete restorative services, and gaps in infection control and confidentiality practices.
Type A—Assessment/record accuracy
Type A—Restorative nursing services
Type A—Care plans and corrective actions
Type A—Medical records documentation
Type A—Clinical record accuracy
Type A—Continence/urinary care planning
Type A—Infection control and prevention
Type A—Confidentiality/Release of information
25 Aug 2011Licensure
25 Aug 2011Licensure
Found no deficiencies. A survey conducted August 22–25, 2011 determined compliance with state requirements.
24 Aug 2011Life Safety
24 Aug 2011Life Safety
Identified multiple life-safety deficiencies at the site, including gaps in fire barriers and unsealed openings, plus issues with smoke detection and egress components.
NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code Standard
NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code Standard
NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code Standard
NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code Standard
NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code Standard
NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code Standard
NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code Standard
16 May 2011Revisit
16 May 2011Revisit
Inspected deficiencies in resident assessments, kitchen sanitation, and medical records. Found issues with documentation, cleanliness, and record-keeping requiring action.
Type A—Resident assessment accuracy and RN signature
Type A—Sanitation/food service deficiencies (dishroom)
Type A—Clinical records
29 Dec 2010Revisit
29 Dec 2010Revisit
Found deficiencies identified and corrections completed; the follow-up confirmed completion of corrections.
483.10(a)(1)&(2)
483.10(b)(11)
483.15(f)(01)
483.20(k)(3)(i)
29 Dec 2010Revisit
29 Dec 2010Revisit
Verified corrections completed for several life-safety and building-code items following a prior issue. No current violations were cited.
14 Oct 2010Complaint
14 Oct 2010Complaint
Investigative findings identified multiple deficiencies related to resident rights notifications, activities, physician notification, infection control, and laboratory testing.
§483.15(b)(1)Notification and contact information for resident rights
—Activities
—Physician notification and clinical changes
—Infection control / handwashing
—Laboratory testing and results
14 Oct 2010Life Safety
14 Oct 2010Life Safety
Multiple life-safety deficiencies were documented, including smoke resistance issues with corridor and barrier doors and problems with the sprinkler system and placement of alcohol-based hand rub dispensers.
NFPA 101 LIFE SAFETY CODE STANDARDCorridor door not smoke resistant
NFPA 101 LIFE SAFETY CODE STANDARDSmoke barrier doors and openings
NFPA 13 - STANDARD FOR THE INSTALLATION OF SPRINKLER SYSTEMSSprinkler system coverage
NFPA 101 LIFE SAFETY CODE STANDARDABHR dispensers not over ignition sources
NFPA 101 LIFE SAFETY CODE STANDARDElectrical safety / wiring
14 Oct 2010Licensure
14 Oct 2010Licensure
Identified noncompliance with state nursing home regulations based on a licensure survey conducted in October 2010.
—LIC REGS FOR NURSING HOMES
17 Dec 2009Revisit
17 Dec 2009Revisit
Identified multiple deficiencies in resident rights, care processes, and administrative requirements, with some corrections completed and others remaining uncorrected after follow-up.
483.13(a)Rights/protections deficiency (general)
483.13(c)(1)(i)-(iii), (c)(2)-(4)Rights/behavior and facility practices deficiency
Completed corrections for life-safety code deficiencies; follow-up confirmed compliance.
NFPA 101Life Safety Code
NFPA 101Life Safety Code
NFPA 101Life Safety Code
NFPA 101Life Safety Code
NFPA 101Life Safety Code
14 Oct 2009Life Safety
14 Oct 2009Life Safety
Found deficiencies related to smoke barriers not meeting smoke-resistance requirements and an unsealed penetration with a cable passing through.
Type ANFPA 101 Life Safety Code StandardSmoke barriers must provide required fire resistance
Type BNFPA 101 Life Safety Code StandardSmoke barrier integrity – penetrations not properly sealed
27 Aug 2009Licensure
27 Aug 2009Licensure
Found safety concerns related to use of restraints and improper staff screening, indicating deficiencies in resident protection and staff controls.
Type A483.13(a)PHYSICAL RESTRAINTS
Type A—EMPLOYEE SCREENING/REGISTRY
27 Aug 2009Licensure
27 Aug 2009Licensure
Concluded that no deficiencies were identified during a recertification survey conducted Aug 24-27, 2009. Found compliance with state regulations.
26 Aug 2009Life Safety
26 Aug 2009Life Safety
Investigators identified multiple Life Safety Code deficiencies, including holes in a shower/bath area, missing sprinkler head covers, and issues with electrical wiring and fire suppression system maintenance.
NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code deficiency
NFPA 101 LIFE SAFETY CODE STANDARDSprinkler system maintenance deficiency
NFPA 101 LIFE SAFETY CODE STANDARDContinued From page 3
NFPA 70, NATIONAL ELECTRICAL CODEElectrical wiring not in full NEC compliance
NFPA 101 LIFE SAFETY CODE STANDARDKitchen hood fire suppression system maintenance
22 Nov 2006Revisit
22 Nov 2006Revisit
Investigated the complaint and identified deficiencies related to residents' rights and care standards.
483.10(e), 483.75(i)(4)
483.15(c)(11)
483.20(k)(1)
483.25(h)
483.65(a)
483.65(c)
22 Nov 2006Revisit
22 Nov 2006Revisit
Verified that all previously cited deficiencies were corrected during the follow-up visit.
06 Sept 2006Life Safety
06 Sept 2006Life Safety
The inspection identified multiple life-safety deficiencies, including improper corridor door closures and malfunctioning emergency lighting. Follow-up actions were documented to address the issues.
NFPA 101 Life Safety Code StandardCorridor doors not maintaining required fire resistance
NFPA 101 Life Safety Code StandardEmergency lighting (generator room)
NFPA 101 Life Safety Code StandardEmergency lighting not illuminated
NFPA Life Safety Code Standard (NFPA 101)Maintenance of life-safety features (fire alarm system)
31 Aug 2006Licensure
31 Aug 2006Licensure
Found multiple deficiencies in resident rights, privacy, assessment and care planning, infection control, housekeeping/maintenance, and nutrition.
483.10(e), 483.75(i)(4)PRIVACY AND CONFIDENTIALITY
483.15(e)(1)ACCOMMODATION OF NEEDS
483.20(g)-(j)RESIDENT ASSESSMENT
483.65(a)INFECTION CONTROL
483.65(b)(3)PREVENTING SPREAD OF INFECTION
483.65(c)INFECTION CONTROL - LINENS
483.60(b)MENUS AND NUTRITIONAL ADEQUACY
02 May 2006Revisit
02 May 2006Revisit
Concluded that previously identified deficiencies were corrected.
02 Feb 2006Licensure
02 Feb 2006Licensure
Investigated deficiencies identified in resident funds management and related administrative controls, with several safety and care-process issues noted.
483.10(c)(2)-(5)Protection of resident funds
11 Jan 2006Life Safety
11 Jan 2006Life Safety
Identified several life-safety deficiencies, including missing sprinkler coverage in several areas, door and corridor issues, unsealed penetrations, and inadequate electrical safety practices.
NFPA 101 Life Safety Code StandardSprinkler protection
NFPA 101 Life Safety Code StandardCorridor walls and door hardware
NFPA 101 Life Safety Code StandardDoor edge gaps
NFPA 101 Life Safety Code StandardUnsealed conduit
NFPA 101 Life Safety Code StandardMaintenance/testing of fire protection systems
NFPA 101 Life Safety Code StandardElectrical receptacle safety
19 Sept 2005Revisit
19 Sept 2005Revisit
Investigated a complaint and found multiple deficiencies cited against regulatory requirements during the revisit.
483.10(b)(11)
483.15(g)
483.15(h)(2)
483.20(b)
483.20(k)(2)
483.20(k)(3)(i)
483.25(e)(2)
483.25(b)(1)
483.25(h)(2)
483.65(c)
483.70(h)(3)
15 Sept 2005Revisit
15 Sept 2005Revisit
Investigated a complaint and found deficiencies; corrections were documented.
25 Aug 2005Complaint
25 Aug 2005Complaint
Investigated the complaint and found no deficiencies.
05 Aug 2005Revisit
05 Aug 2005Revisit
Found life-safety code deficiencies that were addressed.
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