I'm very pleased with the compassionate, attentive staff - CNAs, nurses and rehab therapists went above and beyond to help my parent regain mobility. The facility is clean, recently refreshed inside, serves good food, and offers engaging activities and strong social work/hospice coordination. Residents smile, the team feels like a second family, and I would happily recommend this warm, professional place.
Loved one of resident
Jul 2026
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Amenities
Healthcare services
Activities of daily living assistance
Assistance with bathing
Assistance with dressing
Assistance with transfers
Medication management
Healthcare staffing
24-hour call system
24-hour supervision
Meals and dining
Diabetes diet
Meal preparation and service
Special dietary restrictions
Room
Air-conditioning
Cable
Fully furnished
Housekeeping and linen services
Kitchenettes
Private bathrooms
Telephone
Wifi
Transportation
Community operated transportation
Transportation arrangement
Common areas
Beauty salon
Computer center
Dining room
Fitness room
Gaming room
Garden
Outdoor space
Small library
Wellness center
Community services
Concierge services
Fitness programs
Move-in coordination
Activities
Community-sponsored activities
Planned day trips
Resident-run activities
Scheduled daily activities
Reviews
3.02·(52)
Overall rating
5
4
3
2
1
Care
2.8
Staff
3.2
Meals
2.1
Amenities
2.3
Value
1.0
Pros
Compassionate nursing and CNA staff
Skilled and effective physical and occupational therapy
Engaging daily activities and social outings
Supportive admissions process and social-work coordination
Hospice and comfort-care coordination
Recent interior renovations with improved lighting and flooring
Clean and well-maintained public areas
Family-like, community atmosphere
Individualized care that supported mobility improvements
Clear communication from therapy and some clinical staff
Cons
Chronic understaffing, with acute shortages on weekends
Inconsistent responsiveness to call lights and care requests
Medication-management delays and insulin-administration gaps
Sanitation and odor concerns in some areas
Pest-control concerns
Inconsistent dining quality and limited diabetic meal-planning
Personal belongings and inventory-control lapses
Allegations of unauthorized insurance changes and billing-process issues
High staff turnover and leadership instability
Gaps in family–administration and physician communication
Accessibility and room-layout limitations for mobility-impaired residents
Management and HR culture issues contributing to staff overload
Summary of reviews
The reviews present a mixed but coherent picture: clinical and rehabilitative services are frequently praised while operational and administrative issues appear to create variability in everyday care. Many families and visitors highlight compassionate CNAs, attentive nurses, and a strong therapy program that produced measurable mobility gains. Admissions and social-work coordination, as well as hospice and end-of-life support when needed, were named as strengths. The facility has also undergone visible interior updates — improved lighting and flooring — and many public areas are described as clean and welcoming, contributing to a family-like atmosphere for residents.
Care quality shows two distinct patterns. On the positive side, therapy staff, some nurses, and floor caregivers receive consistent commendations for individualized attention, patience, and the ability to improve functional outcomes. Conversely, operational problems — most notably chronic understaffing (with weekends called out repeatedly) — appear to affect responsiveness, timely assistance with basic needs, and medication administration. Several accounts describe delays in medication or insulin delivery and difficulty locating staff when assistance is required, creating important safety and dignity concerns.
Dining and activities are generally cited as beneficial to resident quality of life. Reviewers mention enjoyable programming, outings, and organized activities (for example, Bingo), and many described food as satisfactory. However, there are recurring notes about inconsistent meal quality and limited diabetic meal-plan availability, which families should verify during any assessment visit.
Facility condition and resident environment show a blend of strengths and issues. The building is older but has received recent renovations in key areas; many reviewers said interior maintenance and lighting have improved. At the same time, there are sanitation and odor concerns reported in some locations, pest-control concerns, and examples of room layouts that are not optimal for mobility-impaired residents. Security of personal items is an operational gap for some families, with multiple instances of missing belongings or identification items noted.
Management and administrative themes are a significant source of variability in the reviews. Positive experiences cite helpful admissions staff, an engaged social worker, and moments of effective administration. Negative themes include high staff turnover, frequent leadership changes, HR-related issues, and perceptions that management priorities sometimes emphasize census over staffing support. Financial and billing processes emerged as a recurring concern, including complaints about unexpected insurance-plan changes and billing handling; these have been described strongly by some families and include allegations of unauthorized insurance changes, underscoring the need for careful review of financial authorizations.
Notable patterns for prospective residents and families: the facility can deliver high-quality therapy and compassionate bedside care, particularly when staffing levels are adequate. However, operational factors — staffing variability, medication-timing issues, sanitation and pest-control concerns, belongings security, and administrative/billing instability — introduce inconsistent experiences. Before making placement decisions, families should verify current staffing ratios (including weekend coverage), confirm diabetic and dietary accommodations, inspect room accessibility, review inventory and personal-property procedures, and request clear documentation of medication administration and insurance/financial authorizations. These due-diligence steps will help align expectations with the facility’s strengths and address the areas where reviewers identified recurring weaknesses.
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Medicare Ratings
1·/ 5
Overall
Health Inspection
Staffing
Quality Measures
Ratings from the U.S. Centers for Medicare & Medicaid Services (Care Compare). View on Medicare.gov
Location
Casper Mountain Rehabilitation and Care Center is located at 4305 S Poplar St, Casper, WY, 82601.
About Casper Mountain Rehabilitation and Care Center
Casper Mountain Rehabilitation and Care Center sits at 4305 S Poplar St in Casper, Wyoming, and operates as a nursing home and skilled nursing facility with a 2-star rating from the Centers for Medicare & Medicaid Services, and an overall score of 6.6 out of 10. The center has studio room layouts for residents, and it keeps its doors open all the time, aiming for continuous service. The place offers both short-term and long-term care, with a staff that covers CNA, LPN, and RN levels. The rehabilitation and care services include special programs, as well as amenities meant for a variety of patient needs, including some features for long-term care and hospital staffing options. There's also a platform set up so clinicians can post and pick up shifts, which covers specialized units like ICU, Med Surg, and ER if needed. Dining services, activity programs, and social services round out daily life. The community aims to make care easier for families and keeps things as clear as possible about the services provided. No extra details are available due to a lack of information from the source and a server error. The facility falls under the categories of assisted living, senior services, rehabilitation, and care. You can find more at caspermountainhc.com.
People often ask...
Casper Mountain Rehabilitation and Care Center offers assisted living, memory care, and skilled nursing.
There are 1 photos of Casper Mountain Rehabilitation and Care Center on Mirador.
The full address for this community is 4305 S Poplar St, Casper, WY 82601.
No, Casper Mountain Rehabilitation and 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-187
Facility type
Nursing Home
Inspection Reports
238
Reports
31
Type A Citations
0
Type B Citations
134
Complaints
21
Years
12 Aug 2025Revisit
12 Aug 2025Revisit
Found no deficiencies.
12 Aug 2025Revisit
12 Aug 2025Revisit
Concluded that all previously cited deficiencies were corrected and no new noncompliance was found.
16 May 2025Complaint
16 May 2025Complaint
Identified failures in wound care management, nursing scope-of-practice adherence, and infection control that led to a resident being hospitalized for a wound-related infection.
CFR 483.25Quality of care
CFR 483.35Competent Nursing Staff
CFR 483.80Infection Control
18 Apr 2025Complaint
18 Apr 2025Complaint
Identified deficiencies in medication administration and record-keeping, including failure to provide medications per physician orders and inadequate control drug records.
§483.45(a)Pharmacy services
§483.45(b)(1)Medication administration
§483.45(b)(2)Records of receipt/disposition of controlled drugs
§483.45(b)(3)Maintaining and reconciling drug records
18 Apr 2025Revisit
18 Apr 2025Revisit
Confirmed all prior deficiencies were corrected and no new noncompliance was found.
18 Apr 2025Revisit
18 Apr 2025Revisit
Verified all prior deficiencies were corrected and no new noncompliance was found.
06 Mar 2025Revisit
06 Mar 2025Revisit
Found inadequate care planning for a resident with a stage 4 pressure ulcer. The care plan did not address the ulcer, and the DON confirmed the deficiency.
§483.21(b)Comprehensive Care Plans
06 Mar 2025Complaint
06 Mar 2025Complaint
Investigation found violations related to visitation rights, physician notification of changes in condition, wound care management, and unnecessary medications.
CFR 483.10(f)(4)Right to Receive/Deny Visitors
CFR 483.10(g)(14)-(15)Notification of Changes
CFR 483.25Quality of Care
CFR 483.45(d)Drug Regimen is Free from Unnecessary Drugs
15 Jan 2025Complaint
15 Jan 2025Complaint
Found deficiencies in handling resident grievances and in implementing a comprehensive care plan, including issues with missing hearing aids and related documentation.
CFR 483.10(j)Grievances
CFR 483.21(b)Develop/Implement Comprehensive Care Plan
08 Jul 2024Revisit
08 Jul 2024Revisit
Found deficiencies in fire alarm testing/maintenance, smoke barrier door closure, and main/feeder circuit breaker testing; deficiencies were corrected and compliance restored.
NFPA 101 Sec. 19.3.4.1, 9.6.1.3; NFPA 72 Table 14.4.5Fire Alarm System - Testing and Maintenance
NFPA 101 Sec. 19.3.7.8, 8.5.4Subdivision of Building Spaces - Smoke Compartments
NFPA 99 Ch.10 Sec. 4.4.1.2Main and Feeder Circuit Breakers - Testing/Maintenance
03 Jul 2024Complaint
03 Jul 2024Complaint
Found no deficiencies identified during the complaint investigation.
13 Jun 2024Licensure
13 Jun 2024Licensure
Found that a qualified full-time licensed administrator was not on the premises to manage the facility.
Ch 11 Sec 5(a) Organization and AdministrationOrganization and Administration
13 Jun 2024Complaint
13 Jun 2024Complaint
Investigated a recertification survey and found multiple deficiencies across resident care, medication management, infection control, kitchen sanitation, staffing data, PASARR, and governance.
The site showed multiple emergency preparedness and life safety deficiencies, including an outdated plan, missing emergency contacts, power and signage issues, obstructed egress, and improper electrical components.
42 CFR 483.73Develop Emergency Plan; Review and Update Annually
42 CFR 483.73(c)(2)Emergency Official Contact Information
42 CFR 483.73(e)Emergency Power
NFPA 101, 2012 edition, 7.1.10Means of Egress - General
NFPA 101, 2012 edition, Sec 19.3.4.1; 9.6.1.3; NFPA 72Fire Alarm System - Testing and Maintenance
NFPA 101, 2012 edition, Sec 19.3.7.8; 8.5.4Subdivision of Building - Smoke Barriers
NFPA 99, 2012 edition, Ch.10 Sec. 4.4.1.2Health Care Facilities Code - Other
NFPA 101, 2012 edition, Sec. 19.5.1.1, 9.1.2; NFPA 70, 2011 edition, Sec. 406.5Electrical Systems - Receptacles
10 Jun 2024Revisit
10 Jun 2024Revisit
Confirmed that previously cited deficiencies were corrected and no new noncompliance was found. All surveyed regulations were met.
03 Jun 2024Revisit
03 Jun 2024Revisit
Concluded all previous deficiencies corrected and no new noncompliance found.
02 May 2024Complaint
02 May 2024Complaint
Identified that the director of nursing provided nursing care without a Wyoming license at hire and licensure verification for the nursing staff was not ensured.
42 CFR 483.70Staff qualifications
21 Mar 2024Complaint
21 Mar 2024Complaint
Investigated complaints found failures to provide necessary hygiene care and to notify physicians about abnormal blood glucose levels.
CFR 483.24(a)(2)ADL Care Provided for Dependent Residents
CFR 483.25Quality of Care
11 Jan 2024Complaint
11 Jan 2024Complaint
Found no deficiencies identified during a complaint survey conducted January 11, 2024.
09 Nov 2023Complaint
09 Nov 2023Complaint
Found no deficiencies related to the complaint investigation.
14 Sept 2023Revisit
14 Sept 2023Revisit
Verified no deficiencies were found during the follow-up visit; all previously cited deficiencies were corrected.
03 Aug 2023Complaint
03 Aug 2023Complaint
Investigated a complaint about visitation during an abuse investigation and the accompanying investigation; found violations of visitation rights and investigation procedures.
483.10(f)(4)(ii)-(v)Right to Receive/Deny Visitors
Investigated a complaint intake and found no deficiencies related to the complaints.
06 Jul 2023Revisit
06 Jul 2023Revisit
Verified that all prior deficiencies were corrected and no new noncompliance was found.
21 Jun 2023Complaint
21 Jun 2023Complaint
Investigated a complaint and found that a timely assessment for a change in resident condition was not completed, leaving no documentation for a hospital transfer for one resident.
42 CFR 483.70(i)Medical records - timely assessment and documentation
26 May 2023Revisit
26 May 2023Revisit
Found no deficiencies. Previous issues were corrected.
22 May 2023Revisit
22 May 2023Revisit
Verified that all deficiencies were corrected and compliance with all requirements was achieved.
18 May 2023Revisit
18 May 2023Revisit
Found no deficiencies; a follow-up visit confirmed compliance with all regulations surveyed.
10 May 2023Revisit
10 May 2023Revisit
Found a door with a self-closing device that failed to latch when released, not meeting life safety requirements. This condition could delay egress during an emergency.
NFPA 101, 7.2.1.8.2Doors with Self-Closing Devices
14 Apr 2023Complaint
14 Apr 2023Complaint
Investigated allegations of staff-to-resident abuse and found failures to report suspicions promptly and to conduct thorough investigations for two residents.
§483.12(b)(5)(i)(A)(B)(c)(1)(4); §483.12(c)Reporting of alleged violations
Found multiple deficiencies in transfer notices, bed-hold notices, care planning, psychotropic medication management, medication labeling, and menu adherence.
CFR 483.15Notice before Transfer/Discharge
CFR 483.15(d)Bed-hold notice upon transfer
CFR 483.21(b)Comprehensive Care Plans
CFR 483.21(b)(2)(i)-(iii)Care Plan Timing and Revision
CFR 483.45Free from Unnecessary Psychotropic Drugs/PRN Use
CFR 483.45(g)-(h)Label/Store Drugs and Biologicals
CFR 483.60Menus
23 Mar 2023Licensure
23 Mar 2023Licensure
Found no deficiencies. The survey determined the facility was in compliance with state requirements.
21 Mar 2023Life Safety
21 Mar 2023Life Safety
Identified multiple deficiencies in emergency preparedness and life safety, including testing, maintenance, and storage practices across fire protection, electrical, and gas/oxygen systems.
42 CFR 483.73(d)(2)Emergency testing requirements
42 CFR 483.73(e)(1) and NFPA 110Emergency and standby power systems
NFPA 101, 2012 edition, 19.2.2.2.4(2)Egress doors
NFPA 101, 2012 edition 7.2.1.8.2Doors with self-closing devices
NFPA 101, 2012 edition 19.2.9.1 and 7.9Emergency lighting
Concluded that no deficiencies were identified during a complaint investigation conducted from 2023-03-01 to 2023-03-02.
02 Feb 2023Revisit
02 Feb 2023Revisit
Verified no deficiencies were found on the follow-up visit; all prior deficiencies were corrected and compliance achieved.
26 Jan 2023Revisit
26 Jan 2023Revisit
Verified that previously cited deficiencies were corrected and found no new noncompliance.
21 Nov 2022Complaint
21 Nov 2022Complaint
Investigated the complaint about discharge notices and found two notices lacked correct information about residents' appeal rights and directed to the wrong agency.
§483.15(c)(3)-(6)(8)Notice Requirements Before Transfer/Discharge
19 Oct 2022Complaint
19 Oct 2022Complaint
Found deficiencies in residents' hygiene care and in nursing staff levels during the investigation.
483.24(a)(2)ADL Care Provided for Dependent Residents
483.35(a)(1)(2)Sufficient Nursing Staff
19 Jul 2022Complaint
19 Jul 2022Complaint
Found no deficiencies. The complaint investigation concluded no deficiencies were identified.
18 Jul 2022Revisit
18 Jul 2022Revisit
Found no deficiencies.
18 May 2022Complaint
18 May 2022Complaint
Investigated a complaint alleging resident abuse and improper use of PRN psychotropic medications; found physical abuse occurred and PRN psychotropic meds were not properly documented or ordered.
§483.12(a)(1)Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion
§483.45(e)(3)-(5)PRN orders for psychotropic drugs; use limited by physician orders and timeframes
10 Mar 2022Revisit
10 Mar 2022Revisit
Concluded that prior deficiencies were corrected and compliance has been restored.
01 Mar 2022Revisit
01 Mar 2022Revisit
Confirmed compliance following a follow-up survey; all prior deficiencies were corrected and no new noncompliance was found.
01 Mar 2022Revisit
01 Mar 2022Revisit
Found all prior deficiencies corrected and no new noncompliance was found.
01 Mar 2022Revisit
01 Mar 2022Revisit
Found no deficiencies.
17 Dec 2021Licensure
17 Dec 2021Licensure
Observed inadequate infection control during COVID-19 testing, with PPE, social distancing, and disinfection not consistently followed. This created an unacceptable risk to resident health.
Ch 11 Sec 6 (b)(i)Infection prevention and control during testing and environmental sanitation
17 Dec 2021Licensure
17 Dec 2021Licensure
Investigated and identified deficiencies across discharge notices, resident safety, catheter and tube feeding management, medication administration, food safety, infection control, immunizations, and COVID-19 procedures.
§483.15(c)(3)-(6)-(8)Notice before transfer/discharge
§483.25(d)(1)-(2)Accidents - supervision and environment
§483.25(e)(1)-(3)Incontinence - urinary and fecal care
§483.25(g)(4)-(5)Tube feeding management
§483.45(f)(1)Medication error rates
§483.60(i)(1)-(2)Food safety - procurement and sanitation
§483.80(a)(1)-(2)(4)(e)(f)Infection prevention and control
§483.80(d)(1)-(2)Influenza and pneumococcal immunizations
§483.80(h)(1)-(6)COVID-19 testing
16 Dec 2021Life Safety
16 Dec 2021Life Safety
Identified multiple life-safety and emergency preparedness deficiencies, including missing emergency contact information, several egress and door issues, missing exit signs, and unsafe decorative and cooking-area conditions.
CFR 483.73(c)(2) and related emergency preparedness regulationsEmergency Officials Contact Information
Found deficiencies in hand hygiene practices related to glove use, with staff not consistently performing hand hygiene after removing gloves.
CFR 483.80Infection Prevention & Control
15 Oct 2021Complaint
15 Oct 2021Complaint
Investigated a complaint alleging abuse and misappropriation; cited deficiencies for abuse and misappropriation with no infection-control deficiencies found.
Type ACFR 483.12(a)Freedom from Abuse, Neglect, and Exploitation
cCFR 483.12(c)Freedom from Misappropriation/Exploitation
27 Aug 2021Complaint
27 Aug 2021Complaint
Investigated a complaint and conducted a focused infection control survey; found no deficiencies.
15 Apr 2021Complaint
15 Apr 2021Complaint
Found no deficiencies.
29 Dec 2020Revisit
29 Dec 2020Revisit
Determined that all prior deficiencies were corrected and no new noncompliance was found.
01 Dec 2020Revisit
01 Dec 2020Revisit
Concluded that all previously cited deficiencies were corrected and no new noncompliance found.
13 Nov 2020Licensure
13 Nov 2020Licensure
Identified deficiencies in infection prevention and control, including improper PPE use and eye protection for staff during COVID-19.
Type A483.80(a)(1)(2)(4)(e)(f)Infection prevention and control
22 Oct 2020Complaint
22 Oct 2020Complaint
Investigated deficiencies in the infection prevention and control program and its annual review, with identified gaps in oversight and documentation.
§483.80(f)Infection prevention and control program — annual review
30 Sept 2020Complaint
30 Sept 2020Complaint
Investigated a complaint and COVID-19 infection-control review; found no deficiencies.
31 Mar 2020Complaint
31 Mar 2020Complaint
Investigated a complaint and conducted a focused infection control survey; found no deficiencies.
10 Mar 2020Revisit
10 Mar 2020Revisit
Verified no deficiencies were found; all prior deficiencies were corrected.
14 Feb 2020Life Safety
14 Feb 2020Life Safety
Verified compliance with life safety code after a follow-up review; previous deficiencies were corrected.
13 Feb 2020Complaint
13 Feb 2020Complaint
Investigated the complaint survey and found no deficiencies identified.
09 Jan 2020Complaint
09 Jan 2020Complaint
Identified deficiencies in timely completion of quarterly MDS assessments for several residents. Three residents’ quarterly MDS assessments were not completed on schedule.
483.20(b)(2)Comprehensive Assessments & Timing
09 Jan 2020Licensure
09 Jan 2020Licensure
Determined the facility was in compliance with State requirements after a survey conducted January 6-9, 2020.
07 Jan 2020Life Safety
07 Jan 2020Life Safety
Investigated findings showed life-safety deficiencies including a malfunctioning self-closing door, hazardous areas lacking required protection, and improper use of electrical power strips.
NFPA 101 Life Safety Code, 2012 edition; Means of egressMeans of egress not maintained
NFPA 101 Life Safety Code, 2012 edition; 19.3.2.1, 19.3.5.9Hazardous areas lacking protection/enclosure
NFPA 101 Life Safety Code, 2012 edition; Electrical Equipment - Power Cords and Extension CordsElectrical power cords/extension cords used improperly
27 Dec 2019Complaint
27 Dec 2019Complaint
Investigated a complaint and found no deficiencies.
17 Oct 2019Revisit
17 Oct 2019Revisit
Verified no deficiencies found after a follow-up review of prior findings.
03 Oct 2019Complaint
03 Oct 2019Complaint
Investigated a complaint and found no deficiencies.
20 Aug 2019Complaint
20 Aug 2019Complaint
Investigated an allegation of abuse involving resident #2 and a misappropriation issue, and another investigation; found that timely reporting to the administrator was not completed in one case and that a separate investigation lacked thoroughness.
Verified that prior life safety deficiencies were corrected and compliance was restored.
02 Apr 2019Revisit
02 Apr 2019Revisit
Concluded that all prior life safety deficiencies were corrected and compliance restored.
19 Mar 2019Revisit
19 Mar 2019Revisit
Verified that all prior deficiencies were corrected and no new noncompliance was found.
10 Jan 2019Complaint
10 Jan 2019Complaint
Found multiple deficiencies across resident funds access, transfer notices and bed-hold information, MDS accuracy, antibiotic use, medication stock, dental services, and food safety.
CFR 483.10(f)(10) and 483.10(f)(10)(i)(ii)Protection/Management of Personal Funds
CFR 483.15(c)(3)-(6)Notice Before Transfer/Discharge
CFR 483.15(d)(1)-(2) and related bed-hold requirementsBed-Hold Notice Upon Transfer
Concluded compliance with state requirements; no deficiencies cited.
08 Jan 2019Life Safety
08 Jan 2019Life Safety
Found multiple life-safety deficiencies including inadequate means of egress, deficiencies in fire alarm testing/maintenance, sprinkler system maintenance gaps, issues with smoke barriers, and unsafe electrical practices.
2012 NFPA 101, Sections: 19.3.2.2.1; 19.3.2.1.3; 9.6.1.5; 2010 NFPA 72, Sections: 14.4.5; 14.6.2.4Means of Egress - General
2010 NFPA 72; NFPA 101Fire Alarm System - Testing and Maintenance
NFPA 101Sprinkler System - Maintenance and Testing CFR(s): NFPA 101
NFPA 101Subdivision of Building Spaces - Smoke Barriers
NFPA 101Electrical Equipment - Power Cords and Extension Cords
08 Jan 2019Life Safety
08 Jan 2019Life Safety
Found a potable water protection deficiency due to sink aerators; aerators in multiple rooms were removed.
Investigated a complaint; found no deficiencies identified.
09 Apr 2018Revisit
09 Apr 2018Revisit
Found that required fire damper testing had not been completed and dampers were not maintained per NFPA standards. This deficiency affected multiple smoke compartments and posed a risk of smoke spread.
Found no deficiencies. A follow-up survey on 2018-04-04 concluded compliance with state requirements.
03 Apr 2018Revisit
03 Apr 2018Revisit
Determined back in compliance after a Life Safety Code revisit; one deficiency was found and later supported by engineer-documented evidence.
Wyoming Rules and Regulations for Licensure of Nursing Care Facilities (Construction Section)Life Safety Code construction requirements
18 Feb 2018Revisit
18 Feb 2018Revisit
Verified compliance with all regulations; no new noncompliance found.
08 Feb 2018Licensure
08 Feb 2018Licensure
Identified two deficiencies: hot-water temperatures exceeded 110 F in multiple locations without proper temperature logging, and no advisory dentist was available.
Ch 11 Sec 6(a)(iv) Physical EnvironmentWater temperature controls
Ch11 Sec 14(a) Dental ServicesDental Services
08 Feb 2018Revisit
08 Feb 2018Revisit
Found no deficiencies. All prior deficiencies were corrected and no new noncompliance was found.
08 Feb 2018Complaint
08 Feb 2018Complaint
Identified multiple deficiencies related to resident rights, infection control, medication management, and discharge planning during the licensing survey.
07 Feb 2018Life Safety
07 Feb 2018Life Safety
The inspection identified multiple life-safety deficiencies related to egress doors, fire protection systems, emergency lighting, and power/electrical safety.
NFPA 101, 2012 Edition (Fire alarm system – Testing/maintenance)Fire alarm system – Testing and maintenance
07 Feb 2018Life Safety
07 Feb 2018Life Safety
Identified modifications to attic truss members behind an attic access panel without approved plans. This raised life-safety concerns.
—State Miscellaneous Life Safety
25 Jan 2018Complaint
25 Jan 2018Complaint
Investigated the complaint and found no deficiencies.
20 Oct 2017Revisit
20 Oct 2017Revisit
Concluded that all previous deficiencies were corrected and no new noncompliance found; in compliance with all regulations surveyed.
04 Oct 2017Revisit
04 Oct 2017Revisit
Verified that previously cited deficiencies were corrected and no new noncompliance was found.
04 Oct 2017Revisit
04 Oct 2017Revisit
Concluded that previous deficiencies were corrected and no new noncompliance was found.
17 Aug 2017Complaint
17 Aug 2017Complaint
Identified deficiencies in residents' assessments and care planning, including failures to complete comprehensive assessments for some residents and to involve residents' representatives in the care planning process.
Type A42 CFR 483.20 (c) – Comprehensive AssessmentsComprehensive Assessments
Type A42 CFR 483.21 (b) – Care PlansCare Plans
17 Aug 2017Licensure
17 Aug 2017Licensure
Determined the operation was in compliance with State requirements. Found no deficiencies.
16 Aug 2017Life Safety
16 Aug 2017Life Safety
Identified life-safety deficiencies including locked egress doors and failure to conduct quarterly fire drills.
7.2.5.4.2Egress Doors
9.1.2Fire Drills
16 Aug 2017Life Safety
16 Aug 2017Life Safety
Investigated deficiencies related to regulatory compliance and safety during a health licensing review.
09 Feb 2017Licensure
09 Feb 2017Licensure
Investigated a deficiency in dental services training and found that dental in-service training was not provided to nursing staff who provide oral hygiene to residents.
CH 11 SEC 14 (a) DENTAL SERVICESDental Services
09 Feb 2017Complaint
09 Feb 2017Complaint
The investigation found several deficiencies in resident care, including inadequate staff attention and medication-management issues, with multiple items continuing across pages and requiring corrective action.
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09 Feb 2017Revisit
09 Feb 2017Revisit
Determined substantial compliance with applicable health and survey requirements; the prior denial of payment for new admissions was rescinded.
09 Feb 2017Revisit
09 Feb 2017Revisit
Determined the provider achieved and maintained substantial compliance as of March 17, 2017 and rescinded the denial of payment for new admissions, enabling continued participation in Medicare/Medicaid.
08 Feb 2017Life Safety
08 Feb 2017Life Safety
Investigated a deficiency related to electrical safety and door hardware; observed missing breakers, unlabelled breakers, and a removed door-closing device.
NFPA 101 - Means of EgressMeans of Egress - General
08 Feb 2017Life Safety
08 Feb 2017Life Safety
Identified a deficiency in electrical safety due to panel boards not installed in accordance with NFPA 70.
NFPA 70Electrical: Panel boards
08 Feb 2017Revisit
08 Feb 2017Revisit
Verified substantial compliance as of March 17, 2017, after follow-up surveys; rescinded the denial of payment for new admissions.
08 Feb 2017Revisit
08 Feb 2017Revisit
Determined substantial compliance with program requirements and rescinded the denial of payment for new admissions, enabling continued participation in Medicare/Medicaid.
31 Jan 2017Revisit
31 Jan 2017Revisit
Completed corrections for six cited deficiencies. All corrective actions were completed as of the revisit date.
Investigated deficiencies previously reported and found corrections completed.
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31 Jan 2017Revisit
31 Jan 2017Revisit
Verified corrective action completed for a previously cited deficiency.
Type ACh 11 Sec 6 (a)(i)ID Prefix S921 deficiency corrected
31 Jan 2017Revisit
31 Jan 2017Revisit
Determined no deficiencies were found on the follow-up visit.
22 Dec 2016Life Safety
22 Dec 2016Life Safety
Identified a deficiency for portable space heaters used in the facility, in violation of the NFPA 101 standard.
NFPA 101 Portable Space HeatersPortable space heaters
22 Dec 2016Life Safety
22 Dec 2016Life Safety
Found a life-safety deficiency for obstructed means of egress due to a portable heater in a location near an exit.
Type ANFPA 101 Life Safety Code, 7.1.1.0.1Means of egress must be kept free of obstructions
15 Dec 2016Complaint
15 Dec 2016Complaint
Investigated deficiencies related to the facility environment and housekeeping. Observations and interviews showed inadequate temperature control and related maintenance issues affecting resident comfort.
Identified multiple deficiencies in treatment changes, reporting of incidents and abuses, and environmental safety and maintenance. The findings showed failures in notifying changes, safeguarding resident property, and ensuring proper temperature and cleaning practices.
Type A—Notify of changes (injury/decline/room, etc.)
Type A—Misappropriation of resident property / abuse reporting
Type A—Temperature/comfort and environmental controls
Type A—Continued from page 16 – sanitation and safety practices
Type A—Storage and sanitation – physical environment
19 Oct 2016Revisit
19 Oct 2016Revisit
Investigated life-safety deficiencies: handrail requirements were not reviewed before installation and sprinkler systems were not maintained or tested as required.
NFPA 101 Life Safety Code StandardLife Safety Code requirements for handrails not reviewed prior to installation
NFPA 101 Life Safety Code StandardAutomatic sprinkler systems not maintained or inspected per NFPA standards
19 Oct 2016Revisit
19 Oct 2016Revisit
Found no deficiencies during the revisit.
10 Oct 2016Revisit
10 Oct 2016Revisit
Corrected deficiencies from a prior survey were completed; the actions were finished by 09/09/2016 and verified on the 10/10/2016 revisit.
Ch 11 Sec 6 (a)(iv)
Ch 11 Sec 6 (b)(v)
10 Oct 2016Revisit
10 Oct 2016Revisit
Investigated and confirmed corrections of previously reported deficiencies; all corrections were completed by the date shown and verified on follow-up.
483.10(c)(2)-(5)
483.10(e), 483.75(l)(4)
483.15(a)
483.15(h)(2)
483.20(b)(2)(ii)
483.55(a)
483.70(h)
483.75(o)(1)
10 Oct 2016Complaint
10 Oct 2016Complaint
Investigated a complaint via a survey conducted from 10/9/16 to 10/10/16. Found no deficiencies.
01 Sept 2016Revisit
01 Sept 2016Revisit
Investigated life-safety deficiencies and related fire-protection issues; multiple NFPA standards not met and corrective actions identified.
NFPA 101 LIFE SAFETY CODE STANDARDContinued From page 1
NFPA LIFE SAFETY CODE STANDARDContinued From page 2
NFPA 101 LIFE SAFETY CODE STANDARDContinued From page 2
29 Jul 2016Life Safety
29 Jul 2016Life Safety
The inspection identified multiple life-safety deficiencies and missing documentation related to electrical wiring, signage for delayed egress, fire-alarm testing, and generator maintenance.
NFPA 101 Life Safety Code StandardPenetrations and fire-caulk disclosure
NFPA 101 Life Safety Code StandardDelayed egress door locking signage
NFPA 101 Life Safety Code StandardFire alarm system testing documentation
NFPA 101 Life Safety Code StandardElectrical wiring and equipment safety
NFPA 101 Life Safety Code StandardFire extinguisher height requirements
NFPA 101 Life Safety Code StandardGenerator inspections/maintenance
NFPA 101 Life Safety Code StandardSystem changes and electrical receptacle inspections
28 Jul 2016Licensure
28 Jul 2016Licensure
Found temperature-control issues and insufficient designation of staff responsible for pet care, with related unsanitary conditions observed.
Type ACh 11 Sec 6 (a) (iv) Physical EnvironmentPhysical Environment
Type ACh 11 Sec 6 (b) (v) Physical EnvironmentPhysical Environment
28 Jul 2016Complaint
28 Jul 2016Complaint
Found deficiencies in privacy and confidentiality of records, resident funds, and overall care planning and facility operations, indicating multiple areas needing improvement.
—Personal Privacy/Confidentiality of Records
—Comprehensive Assessments
—Provision of Medically Related Social Services
—Infection Control
—Safe/Functional/Sanitary/Comfortable Environment
—Quality Assurance and Performance Improvement (QAPI)
—Routine/Emergency Dental Services
10 May 2016Life Safety
10 May 2016Life Safety
Investigated the complaint and found no deficiencies.
04 Apr 2016Revisit
04 Apr 2016Revisit
Verified that previously cited life safety code deficiencies were corrected.
NFPA 101 Life Safety CodeK0018 – Life Safety Code deficiency
NFPA 101 Life Safety CodeK0046 – Life Safety Code deficiency
NFPA 101 Life Safety CodeK0052 – Life Safety Code deficiency
21 Mar 2016Revisit
21 Mar 2016Revisit
Identified deficiencies in life-safety system maintenance and monitoring, including generator testing and fire alarm maintenance, found during a post-certification revisit.
NFPA 110; NFPA 99Generator maintenance and testing
NFPA 101 Life Safety Code Standard; Sections 19.2.9.1 and 7.9.3Generator maintenance and testing
NFPA 101 Life Safety Code Standard; NFPA 72Fire alarm system testing/maintenance
NFPA 101 Life Safety Code StandardMonitoring and oversight of corrective actions
21 Mar 2016Revisit
21 Mar 2016Revisit
Verified prior deficiencies were corrected and no new violations identified.
16 Mar 2016Revisit
16 Mar 2016Revisit
Verified prior deficiencies were corrected.
483.20(k)(3)(i)
483.25
483.25(d)
16 Mar 2016Revisit
16 Mar 2016Revisit
Verified corrections completed for two deficiencies previously cited in CMS-2567.
483.13(c)
483.25(c)
16 Mar 2016Revisit
16 Mar 2016Revisit
Identified and corrected multiple deficiencies from prior findings during a follow-up review; the corrections were completed and dated 03/16/2016.
483.10(b)(11)
483.10(f)(2)
483.12(a)(4)-(6)
483.60(a),(b)
483.70(h)
483.15(h)(2)
16 Mar 2016Revisit
16 Mar 2016Revisit
Verified that previously reported deficiencies were corrected and follow-up actions completed.
16 Mar 2016Complaint
16 Mar 2016Complaint
Investigated the complaint intake and related survey; determined that no deficiencies were identified.
10 Feb 2016Complaint
10 Feb 2016Complaint
Investigated a complaint and found deficiencies in wound care documentation and ongoing wound management.
—Wound care documentation/assessment
15 Jan 2016Complaint
15 Jan 2016Complaint
The inspection identified a deficiency related to medication administration, showing that insulin doses were not provided to a resident as prescribed and were inconsistently documented.
—Medication administration deficiency (insulin not given as prescribed)
15 Jan 2016Licensure
15 Jan 2016Licensure
Identified hot water temperatures above 110°F in multiple sinks during the visit.
Found deficiencies in diabetes monitoring/insulin administration, medication order audits, catheter management, and nurse staffing oversight.
Type A—Diabetes management/insulin monitoring
—Audit of medication and treatment orders; monitoring
—Urinary catheter management and UTI prevention
—Nurse staffing and compliance monitoring
15 Jan 2016Complaint
15 Jan 2016Complaint
Investigated a complaint and found multiple deficiencies related to residents' financial protections, grievance rights, and discharge processes, with several corrective actions planned.
Type A—Notice of Rights/Financial Resources
Type A—Right to Prompt Efforts to Resolve Grievances
Type A—Transfer/Discharge
12 Jan 2016Life Safety
12 Jan 2016Life Safety
Determined a life-safety ventilation issue in the 400 hallway, with re-routed ductwork and each room venting directly to the outside.
2008 IMC, Section 102.3IMC Life Safety - International Mechanical Code
12 Jan 2016Life Safety
12 Jan 2016Life Safety
Identified several life-safety deficiencies at the site, including issues with smoke door resistance, signage, and maintenance of fire protection systems.
NFPA 101 Life Safety Code StandardDoors and smoke resistance
NFPA 101 Life Safety Code StandardExit signage
NFPA 101 Life Safety Code StandardBattery-operated lighting / transfer switch
NFPA 101 Life Safety Code StandardSprinkler system maintenance
NFPA 101 Life Safety Code StandardGenerator maintenance
NFPA 101 Life Safety Code StandardEmergency power / generator testing
NFPA 101 Life Safety Code StandardSignage and clearance
16 Dec 2015Revisit
16 Dec 2015Revisit
Found corrections completed for identified deficiencies and confirmed through follow-up.
02 Dec 2015Complaint
02 Dec 2015Complaint
Investigated the complaint and found that no deficiencies were identified.
02 Dec 2015Life Safety
02 Dec 2015Life Safety
Investigated the complaint and found no deficiencies.
18 Nov 2015Complaint
18 Nov 2015Complaint
Identified deficiencies in care planning and monitoring, including failure to develop a comprehensive care plan for a resident.
—Provide Care/Services for Highest Well Being
06 Nov 2015Complaint
06 Nov 2015Complaint
Investigated a resident-to-resident incident and found that required incident reporting to the licensing authority and CMS was not completed.
—Investigation/Report Allegations/Individuals
23 Jul 2015Complaint
23 Jul 2015Complaint
Investigated a complaint from July 2015 and found no deficiencies.
07 Jul 2015Revisit
07 Jul 2015Revisit
Investigated follow-up and confirmed corrections of life-safety deficiencies; all cited items were corrected by the designated date.
Life Safety Code (LSC) / NFPA 101Life safety code deficiencies
07 Jul 2015Revisit
07 Jul 2015Revisit
Verified that corrective actions from earlier concerns were completed after a follow-up visit.
02 Jul 2015Revisit
02 Jul 2015Revisit
Investigated a regulatory matter and identified multiple deficiencies; all corrections were completed.
483.13(c)(1)(ii)-(iii), (c)(2)-(4)
483.15(a)
483.15(g)(1)
483.15(h)(2)
483.20(b)(2)(i)
483.20(d)(3), 483.10(k)(2)
483.25(a)(3)
483.20(b)(2)
483.25(n)
483.35(f)
483.65
02 Jun 2015Complaint
02 Jun 2015Complaint
Investigated the complaint intake and found no deficiencies.
30 Apr 2015Complaint
30 Apr 2015Complaint
Identified multiple deficiencies including lack of dignity and respect for residents, inadequate quality-of-life and rights protections, and deficiencies in housekeeping and maintenance.
—Dignity and Respect of Individuality
—Quality of Life, Resident's Rights
—Housekeeping and Maintenance Services
30 Apr 2015Licensure
30 Apr 2015Licensure
Determined that the facility was in compliance with state requirements after a multi-day survey.
29 Apr 2015Life Safety
29 Apr 2015Life Safety
Found life-safety deficiencies related to storage and administration area compliance with NFPA 101, and backflow prevention/eyewash provisions in chemical dispensing and related systems.
NFPA 101 Life Safety Code StandardStorage and administration area incomplete with NFPA 101 Life Safety Code Standard
IPC Life SafetyBackflow prevention and eyewash compliance
29 Apr 2015Life Safety
29 Apr 2015Life Safety
Investigated life-safety deficiencies involving smoke barrier penetrations, improperly sealed doors, and gate and alarm-system concerns; several items were found non-compliant.
NFPA 101 Life Safety Code StandardCODE
NFPA 101 Life Safety Code StandardCODE
NFPA 101 Life Safety Code StandardCODE
NFPA 101 Life Safety Code StandardLIFE SAFETY CODE STANDARD
NFPA 101 Life Safety Code StandardCODE
NFPA 101 Life Safety Code StandardCODE
NFPA 101 Life Safety Code StandardCODE
NFPA 101 Life Safety Code StandardCODE
NFPA 101 Life Safety Code StandardCODE
NFPA 101 Life Safety Code StandardCODE
27 Apr 2015Revisit
27 Apr 2015Revisit
Investigated a follow-up after prior deficiencies and found that corrections were completed.
16 Apr 2015Revisit
16 Apr 2015Revisit
Found problems with infection control practices and quality assurance processes, including issues with storage and oversight of procedures.
—Infection control (infection control, prevent spread, linens)
—Quality Assurance/Performance Improvement (QAPI) program
16 Apr 2015Revisit
16 Apr 2015Revisit
Identified no deficiencies after the post-certification revisit; corrections were completed.
16 Apr 2015Revisit
16 Apr 2015Revisit
Investigated the prior deficiencies and confirmed correction of all cited items.
18 Mar 2015Complaint
18 Mar 2015Complaint
Identified deficiencies in wound care management, change‑of‑condition notifications, and recordkeeping, with missing orders and incomplete documentation.
—Continued from page 3: wound care and documentation
—Notify of changes (injury/decline/room, etc.)
—Records complete/accurate/accessibile
04 Mar 2015Complaint
04 Mar 2015Complaint
Investigated the facility found deficiencies in grievance investigations, staffing adequacy, infection control, and ventilation and general resident care processes.
—Grievance investigations and resident notification
—Adequate staffing and coverage
—Infection control program and practices
—Adequate outside ventilation
—No catheter/urinary care-related deficiencies
04 Mar 2015Revisit
04 Mar 2015Revisit
The inspection identified deficiencies related to nursing staffing levels and the adequacy of care and services provided to residents.
42 CFR 483.35Sufficient 24-hour nursing staffing per care plans
04 Mar 2015Revisit
04 Mar 2015Revisit
Found no deficiencies. The revisit indicated full compliance with applicable requirements.
06 Jan 2015Complaint
06 Jan 2015Complaint
Investigation found deficiencies in bowel elimination management, daily living care, and staffing plans, with extensive documentation gaps and care planning issues.
—Bowel elimination and constipation management
—Daily living and personal care staffing/assistance
—Daily living staffing to meet residents’ care needs; bathing and related services
11 Dec 2014Complaint
11 Dec 2014Complaint
Found a resident had a significant change in condition and staff did not promptly notify the physician or guardian, and guardian contact information was not updated in the records.
—Significant change in condition; monitoring and notification deficiencies
29 Oct 2014Revisit
29 Oct 2014Revisit
Verified corrections were completed for previously reported deficiencies and noted on follow-up activities.
483.15(a)
483.20(b)(2)(ii)
483.20(d), 483.20(k)(1)
483.25(k)
483.70(h)(4)
01 Oct 2014Revisit
01 Oct 2014Revisit
Investigated infection-control practices and found a deficiency related to wound dressing changes.
483.65Infection control
01 Oct 2014Revisit
01 Oct 2014Revisit
Investigated and found infection control measures not adequately implemented, including improper wound dressing changes.
F-441Infection Control
15 Aug 2014Revisit
15 Aug 2014Revisit
Identified deficiencies in safety hazards and infection control during a follow-up review, indicating ongoing risk to residents.
483.25(k)Freedom from accident hazards; adequate supervision
—Infection Control Program; prevent, spread of infection
15 Aug 2014Complaint
15 Aug 2014Complaint
Identified multiple deficiencies in resident care planning, monitoring, and staff practices during the licensing review.
—Continued deficiencies related to care planning and interdisciplinary review
—Continued deficiencies in care planning and monitoring (pages 3-4)
—Residency care planning and weight monitoring (page 3)
—Discharge-related deficiencies (page 4)
—Care for highest well-being (page 5)
—System measures and monitoring (page 5-6)
—Nursing staffing and patient care oversight (page 7-9)
—Staff scheduling and care planning (page 16-17)
—Physician visits – timing and timeliness (page 18-19)
—Emergency dental services (page 18-19)
16 May 2014Complaint
16 May 2014Complaint
An investigation found multiple deficiencies in resident care, safety, infection control, and environmental management, with several pages detailing ongoing corrective actions.
—
—
—
—
—
13 Mar 2014Revisit
13 Mar 2014Revisit
Investigated alleged deficiencies in resident care and rights standards; corrections were completed.
483.15(a)
483.20(d); 483.20(k)(1)
483.20(k)(3)(ii)
483.15(h)(2)
483.25(a)(3)
483.70(h)(2)
483.65
483.70(h)
483.70(h)(2)
483.75(l)(1)
483.75(o)(1)
21 Feb 2014Revisit
21 Feb 2014Revisit
Found no deficiencies; corrections completed during follow-up.
21 Feb 2014Revisit
21 Feb 2014Revisit
Found no deficiencies cited after the revisit.
11 Feb 2014Life Safety
11 Feb 2014Life Safety
The investigation found multiple deficiencies related to egress door locking, separation of hazardous areas, fire drills, and building systems maintenance.
Determined that the dietetic manager did not meet qualification requirements to supervise dietetic services, indicating noncompliance with dietary supervision standards.
Type ACh 11 Sec 11 (a)(i)Dietetic Services
07 Jan 2014Life Safety
07 Jan 2014Life Safety
Investigated life-safety concerns found several deficiencies: corridor doors not closing as required, inadequate protective plates around doors, and the central station certificate was not posted.
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
12 Jun 2013Complaint
12 Jun 2013Complaint
Investigated concerns about how constipation was managed and documented; findings showed issues with following bowel protocol and nursing documentation related to the resident's condition.
—Bowel management and documentation deficiencies
03 May 2013Complaint
03 May 2013Complaint
Found that one of three investigations was not thorough and complete, with insufficient interviews and documentation.
—Investigate/Report Allegations/Individuals
25 Apr 2013Revisit
25 Apr 2013Revisit
Concluded substantial compliance after follow-up corrections were completed and verified.
483.15(a)
483.20(d), 483.20(k)(1)
483.20(k)(3)(ii)
483.25(a)(3)
483.25(c)
483.25(h)
483.25(i)(3)
22 Feb 2013Complaint
22 Feb 2013Complaint
Inspections found multiple deficiencies related to nutrition, weight management, safety, and care planning. Documentation showed failure to implement a comprehensive care plan and to consistently follow through on dietary and safety needs.
—Care plan deficiencies related to nutrition and weight
—Nutrition/dietary service delivery not aligned with plan
—Safety and falls risk oversight inadequate
—Weight management and nutrition plan not fully implemented
—Systemic changes and staff training not completed
—Admissions safety education not documented
—Weight and nutrition status monitoring deficiencies
18 Oct 2012Complaint
18 Oct 2012Complaint
Identified multiple deficiencies in resident care, documentation, and infection control, including incomplete MDS assessments, missing bowel movement documentation, and gaps in snack provision and outbreak surveillance.
—Comprehensive MDS assessment not completed
—Documentation of bowel movements
—Snack provision at bedtime
—Infection control program deficiencies
16 Oct 2012Life Safety
16 Oct 2012Life Safety
Investigated a deficiency; several life-safety issues were identified, including problems with emergency lighting, sprinkler maintenance, and fire-related safety signage and components.
NFPA 101 Life Safety Code StandardEmergency lighting and related life-safety requirements
NFPA 101 Life Safety Code StandardFire-resistance construction and automatic extinguishing systems
NFPA 101 Life Safety Code StandardAlarm system – continued deficiencies
NFPA 101 Life Safety Code StandardSprinkler system maintenance
NFPA 101 Life Safety Code StandardCurtains, draperies and similar fabrics
NFPA 99; 8.6.4.2Non-smoking signage and oxygen-area signage
NFPA 101 Life Safety Code StandardElectrical safety – cords and outlets
08 Aug 2012Revisit
08 Aug 2012Revisit
Investigated a follow-up after prior findings and confirmed corrections completed.
483.25(h)
483.30(e)
483.75(f)
08 Jun 2012Revisit
08 Jun 2012Revisit
Investigated a follow-up; found no deficiencies cited.
07 Jun 2012Complaint
07 Jun 2012Complaint
Discovered deficiencies in nurse aide competency documentation and in posting daily staffing data. Noted missing competency assessments and training records for several aides.
—Continued From page 2 - Nursing staff competency and training
—Monitoring
—Continued From page 4 - Nursing staff competency and training
06 Dec 2011Complaint
06 Dec 2011Complaint
Investigated a complaint and found no deficiencies.
23 Nov 2011Revisit
23 Nov 2011Revisit
Found deficiencies and cited regulatory violations during the follow-up review; several corrections completed.
483.15(c)(6)
483.20(g) - (i)
483.20(d), 483.20(k)(1)
483.20(d)(3), 483.10(k)(2)
483.25
483.25(h)
483.35(i)
483.65
483.70(h)
04 Nov 2011Revisit
04 Nov 2011Revisit
Investigated a complaint and found life-safety deficiencies that were subsequently corrected.
Type ANFPA 101 Life Safety CodeLife Safety Code deficiency
Type ANFPA 101 Life Safety CodeLife Safety Code deficiency
Type ANFPA 101 Life Safety CodeLife Safety Code deficiency
Type ANFPA 101 Life Safety CodeLife Safety Code deficiency
04 Nov 2011Revisit
04 Nov 2011Revisit
Found no deficiencies.
22 Sept 2011Life Safety
22 Sept 2011Life Safety
Identified life-safety and fire-code deficiencies including doors in smoke barriers lacking proper protections and other life-safety concerns; several entries describe noncompliance with established codes.
Type ANFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code
Type AFIRE CODEFire Code
Type ANFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code
22 Sept 2011Licensure
22 Sept 2011Licensure
Found deficiencies in care planning, resident safety, and infection control across multiple areas with several deficiencies identified.
—Summary statement of deficiencies (each deficiency must be preceded by regulatory or LSC identifying information)
—Continued From page 3; Comprehensive care plan required
—Continued From page 9; Plan of correction cross-referenced to deficient areas
—Continued From page 13; Infection control and sanitation
—Continued From page 15; Safe, functional, sanitary environment
22 Sept 2011Licensure
22 Sept 2011Licensure
Identified deficiencies in care planning; care plans were not adequately developed with measurable goals and timelines.
—Comprehensive care plans
22 Sept 2011Licensure
22 Sept 2011Licensure
Concluded compliance with state requirements after a licensure survey conducted from 9/19/2011 to 9/22/2011.
17 Aug 2011Revisit
17 Aug 2011Revisit
Verified corrections were completed and substantial compliance achieved after a follow-up visit.
16 Jun 2011Complaint
16 Jun 2011Complaint
Investigated an allegation of abuse/neglect and found deficiencies in timely reporting and thorough investigation.
Type A—Failure to report and thoroughly investigate abuse/neglect
Type A—Audit of incidents and reporting/investigation patterns
18 Jan 2011Revisit
18 Jan 2011Revisit
Verified that previously reported deficiencies were corrected during the follow-up visit.
07 Jan 2011Revisit
07 Jan 2011Revisit
Investigated the complaint and found no deficiencies.
18 Nov 2010Licensure
18 Nov 2010Licensure
Identified that the dietary manager did not meet the required qualifications.
SNH Section 11Dietary manager qualifications
18 Nov 2010Complaint
18 Nov 2010Complaint
Investigated an allegation of deficiencies and found multiple issues in resident care, safety, and documentation.
Type A—Continued From page 1
Type A—Monitoring
Type A—Corrective Action
Type A—Cross-reference to corrective actions
18 Nov 2010Revisit
18 Nov 2010Revisit
Concluded substantial compliance following the revisit; prior deficiencies were corrected.
17 Nov 2010Life Safety
17 Nov 2010Life Safety
Identified multiple life-safety deficiencies, including missing exit signage, inadequate lighting and emergency illumination, corroded sprinkler heads, improper fire barriers, and ventilation/curtains not meeting standards.
NFPA 101 Life Safety Code Standard 7.10.1.4Exit signage missing
NFPA 101 Life Safety Code Standard 19.2.8Exit lighting illumination
NFPA 101 Life Safety Code StandardExit signage/lighting deficiencies
NFPA 101 Life Safety Code StandardDrills and records
NFPA 101 Life Safety Code StandardSprinkler system maintenance
NFPA 101 Life Safety Code StandardHVAC compliance
NFPA 701 Life Safety Code StandardCurtains and draperies flame resistance
NFPA 101 Life Safety Code StandardTransfer of oxygen safety
14 May 2010Complaint
14 May 2010Complaint
Investigated the complaint; found no deficiencies.
14 May 2010Complaint
14 May 2010Complaint
Investigated a complaint and found no deficiencies identified.
31 Dec 2009Revisit
31 Dec 2009Revisit
Investigated deficiencies and confirmed corrections completed; no uncorrected deficiencies remained.
483.15(a)
483.15(h)(2)
483.20(b)
483.20(d)
483.20(k)(3)(i)
483.20(k)(3)(ii)
483.25
483.25(d)
483.60(a) / 483.60(b)
483.25(b)
483.25(m)(1)
483.25(n)
483.60(a) / 483.60(b)
483.60(a)
31 Dec 2009Revisit
31 Dec 2009Revisit
Investigated deficiencies from a prior visit; corrections were completed.
02 Dec 2009Revisit
02 Dec 2009Revisit
Concluded that corrections from a prior survey were completed; no deficiencies were cited on this revisit.
23 Oct 2009Licensure
23 Oct 2009Licensure
Identified deficiencies in the dental services program due to the lack of an advisory dentist and missing in-service education records.
Wyoming Rules and Regulations for Nursing Care Facilities Chapter 11, Section 14Dental Services
23 Oct 2009Complaint
23 Oct 2009Complaint
The facility had several deficiencies related to resident dignity, comprehensive assessments and care planning, and immunization practices, indicating non-compliance with several care standards.
483.15(a)DIGNITY
483.20(k)(2)COMPREHENSIVE ASSESSMENTS
483.25QUALITY OF CARE
483.25(n)INFLUENZA AND PNEUMOCOCCAL IMMUNIZATION
20 Oct 2009Life Safety
20 Oct 2009Life Safety
The inspection identified several life-safety deficiencies, including lack of quarterly testing of a supervisory signal device, incomplete maintenance documentation, and unnoted receptacle maintenance; corrective actions had been begun.
NFPA 101 LIFE SAFETY CODE STANDARDContinued From page 2 – Supervisory signal device testing
NFPA 101 LIFE SAFETY CODE STANDARD; NFPA 70 NATIONAL ELECTRICAL CODEElectrical wiring and equipment – compliance with NFPA 70 and NFPA 101
NFPA 101 LIFE SAFETY CODE STANDARDContinued From page 3 – Receptacle maintenance/log documentation
NFPA 101 LIFE SAFETY CODE STANDARDContinued From page 3 – Maintenance log and receptacle documentation
02 Apr 2009Complaint
02 Apr 2009Complaint
Investigated a complaint and found no deficient practices identified.
20 Feb 2009Complaint
20 Feb 2009Complaint
Investigated a complaint; no deficiencies identified.
29 Oct 2008Revisit
29 Oct 2008Revisit
Investigated deficiencies; multiple regulatory violations were cited and subsequently corrected.
29 Oct 2008Revisit
29 Oct 2008Revisit
Investigated prior deficiencies and confirmed corrective actions were completed.
20 Oct 2008Revisit
20 Oct 2008Revisit
Identified life-safety deficiencies. Corrections were completed by 2008-10-09.
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 Oct 2008Revisit
20 Oct 2008Revisit
Investigated a follow-up after a prior deficiency; corrections were completed for cited life-safety deficiencies.
NFPA 101 Life Safety CodeLife Safety Code violation
NFPA 101 Life Safety CodeLife Safety Code violation
NFPA 101 Life Safety CodeLife Safety Code violation
NFPA 101 Life Safety CodeLife Safety Code violation
28 Aug 2008Licensure
28 Aug 2008Licensure
Investigated the allegation of inadequate resident care and oversight, with multiple deficiencies identified in notification of changes, staff treatment of residents, and care planning/documentation.
483.10(b)(11)NOTIFICATION OF CHANGES
483.13(c)STAFF TREATMENT OF RESIDENTS
483.20(k)(3)(i)SOCIAL SERVICES
483.20(k)(3)(i)COMPREHENSIVE CARE PLANS
483.25PRESSURE SORES
483.60SANITARY CONDITIONS
26 Aug 2008Revisit
26 Aug 2008Revisit
Investigated a complaint and found deficiencies related to residents' rights and facility practices; corrective actions were noted as completed.
483.13(c)(1)(ii)-(iii), (c)(2)-(4)Residents' rights
483.20, 483.20(b)
483.20(c)
26 Aug 2008Life Safety
26 Aug 2008Life Safety
Found deficiencies in life-safety code compliance, including missing automatic closing devices, sprinkler head clearance issues, and improper storage of oxygen-related equipment.
NFPA 101 LIFE SAFETY CODE STANDARDAutomatic closing device missing
NFPA 101 LIFE SAFETY CODE STANDARDSprinkler head too close to wall
NFPA 101 LIFE SAFETY CODE STANDARDDecorations/furnishings not in accordance with NFPA requirements
NFPA 101 LIFE SAFETY CODE STANDARDOxygen storage and related hazards
12 Jun 2008Complaint
12 Jun 2008Complaint
Investigated alleged misconduct and failures to report and document resident assessments. Found deficiencies in staff reporting of an alleged theft, incomplete and missing comprehensive assessments for falls, and failure to conduct quarterly reviews.
483.13(c)(1)(ii)-(iii), (c)(2)-(4)Staff Treatment of Residents
Verified corrections completed for previously cited deficiencies.
483.12(a)(4)-(6)483.12(a)(4)-(6) Life Safety Code
25 Jan 2008Revisit
25 Jan 2008Revisit
Verified corrections from the prior survey were completed.
21 Nov 2007Complaint
21 Nov 2007Complaint
Investigated discharge planning; identified missing discharge plan of care and missing discharge summary for a resident who was discharged.
42 CFR 483.20Transfer and Discharge Requirements
42 CFR 483.20Discharge Summary
20 Sept 2007Revisit
20 Sept 2007Revisit
Verified corrections for previously cited deficiencies; achieved substantial compliance.
483.15(a)
483.15(h)(2)
483.20, 483.20(b)
483.25(a)(2)
483.20(k)(3)(ii)
483.25(l)
22 Aug 2007Revisit
22 Aug 2007Revisit
Verified corrections were completed for previously cited deficiencies.
12 Jul 2007Complaint
12 Jul 2007Complaint
Found that care was not consistently provided according to residents' written plans, affecting residents' dignity.
483.15(a)(2)DIGNITY
27 Jun 2007Life Safety
27 Jun 2007Life Safety
Several life-safety deficiencies were identified, including door hardware problems, unsealed penetrations in fire barriers, and unsafe electrical practices, indicating non-compliance with applicable standards.
NFPA 101 LIFE SAFETY CODE STANDARDCorridor door hardware and closings
NFPA 101 LIFE SAFETY CODE STANDARDSmoke barrier penetrations not sealed
NFPA 101 LIFE SAFETY CODE STANDARDSmoke barrier openings and closures
NFPA 101 LIFE SAFETY CODE STANDARDSprinkler system coverage – installation
NFPA 101 LIFE SAFETY CODE STANDARDSprinkler system maintenance
NFPA 101 LIFE SAFETY CODE STANDARDElectrical safety – extension cords
NFPA 101 LIFE SAFETY CODE STANDARDExtension cords and life-safety equipment management
20 Apr 2007Complaint
20 Apr 2007Complaint
Investigated a complaint and found no deficiencies identified.
20 Apr 2007Complaint
20 Apr 2007Complaint
Investigated a complaint and found no deficiencies.
21 Nov 2006Complaint
21 Nov 2006Complaint
Found no deficiencies identified in two complaint investigations.
21 Nov 2006Complaint
21 Nov 2006Complaint
Investigated two complaint investigations conducted; found no deficiencies identified.
23 Jun 2006Revisit
23 Jun 2006Revisit
Investigated a complaint and followed up on previously reported deficiencies; corrections were completed for several items by the revisit.
23 Jun 2006Revisit
23 Jun 2006Revisit
Verified corrections addressed previously cited deficiencies; no uncorrected deficiencies remained.
22 May 2006Revisit
22 May 2006Revisit
Investigated and found life-safety deficiencies with corrections completed.
NFPA 101; Life Safety Code (LSC) K0018Life Safety Code deficiency
NFPA 101; Life Safety Code (LSC) K0029Life Safety Code deficiency
NFPA 101; Life Safety Code (LSC) K0051Life Safety Code deficiency
12 May 2006Licensure
12 May 2006Licensure
The investigation identified multiple deficiencies related to resident rights, assessments, care planning, and nursing staff practices, indicating several areas where requirements were not met.
483.13(c)(1)(ii)-(iii)Staff treatment of residents
483.20(g)-(j)Resident assessment – continued deficiencies
483.25Quality of care
06 Apr 2006Licensure
06 Apr 2006Licensure
Identified deficiencies across several areas, including resident assessments, cleanliness and maintenance, daily living support, infection control, and medication labeling.
Observed multiple life-safety deficiencies, including sprinkler system maintenance failures and inadequate smoking supervision, with required corrective actions identified.
CMS regulations prohibiting roller latchesLIFE 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
10 Jan 2006Complaint
10 Jan 2006Complaint
Found no deficiencies after two complaint investigations.
10 Jan 2006Complaint
10 Jan 2006Complaint
Investigated two complaints and found no deficiencies.
24 May 2005Revisit
24 May 2005Revisit
Investigated the complaint and identified multiple deficiencies related to resident rights, quality of life, and care practices; corrections completed.
483.15(g)Resident rights
483.20(c)Admission, Transfer and Discharge
483.20(d)(2)Notification/Disclosure requirements
483.20(d)Discharge/Transfer protections
483.25(a)(2)Quality of life
483.25(d)(2)Quality of life
483.75(i)Rights/other regulatory provisions
483.60(d)(2)Environmental/Physical safety
483.70(h)Resident activities/rights
483.75(i)Quality of care/other
24 May 2005Complaint
24 May 2005Complaint
Investigated the complaint survey; found no deficiencies identified.
06 Apr 2005Revisit
06 Apr 2005Revisit
Verified corrections were completed and compliance achieved.
24 Mar 2005Licensure
24 Mar 2005Licensure
An investigation found deficiencies in resident health monitoring and care planning, including unsafe mental health indicators and incomplete/unsupported resident assessments.
—Mental health safety and monitoring
—RESIDENT ASSESSMENT
09 Feb 2005Life Safety
09 Feb 2005Life Safety
Identified multiple life-safety deficiencies across hazardous area separation, fire alarm and sprinkler systems, electrical safety, signage, and storage of flammable liquids.
NFPA 101 19.3.2.1Hazardous areas separation
NFPA 72Fire alarm system maintenance
NFPA 72; NFPA 25; NFPA 99Fire alarm system maintenance/testing/documentation
NFPA 25Spare sprinkler heads
NFPA 70Electrical safety – cords and power strips
NFPA 99 8.6.4.2Oxygen signage
NFPA 101No smoking signage
NFPA 30; NFPA 101; NFPA 45Flammable liquids handling and storage
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