Casper Mountain Rehabilitation and Care Center

    4305 S Poplar St, Casper, WY 82601
    • Assisted Living
    • Memory Care
    • Skilled Nursing

    Compassionate staff, clean, engaging care

    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

    1. 5
    2. 4
    3. 3
    4. 2
    5. 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

    Map showing location of Casper Mountain Rehabilitation and Care Center

    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 numbernh-187
    Facility typeNursing Home

    Inspection Reports

    238

    Reports

    31

    Type A Citations

    0

    Type B Citations

    134

    Complaints

    21

    Years

    12 Aug 2025Revisit
    Found no deficiencies.
    12 Aug 2025Revisit
    Concluded that all previously cited deficiencies were corrected and no new noncompliance was found.
    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
    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
    Confirmed all prior deficiencies were corrected and no new noncompliance was found.
    18 Apr 2025Revisit
    Verified all prior deficiencies were corrected and no new noncompliance was found.
    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
    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
    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
    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
    Found no deficiencies identified during the complaint investigation.
    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
    Investigated a recertification survey and found multiple deficiencies across resident care, medication management, infection control, kitchen sanitation, staffing data, PASARR, and governance.
    • CFR 483.10(g)(17)-(18)Medicaid/Medicare Coverage/Liability
    • CFR 483.20(k)(1)-(3)PASARR Screening for MD & ID
    • CFR 483.24(a)(2)ADL Care Provided for Dependent Residents
    • CFR 483.35(g)(1)-(4)Posted Nurse Staffing Information
    • CFR 483.45(g)-(h)Label/Store Drugs and Biologicals; Storage of Drugs
    • CFR 483.60(i)Food Procurement,Store/Prepare/Serve-Sanitary
    • CFR 483.70(d)Governing Body
    • CFR 483.80(a)Infection Prevention & Control
    • CFR 483.90(d)(2)Essential Equipment, Safe Operating Condition
    12 Jun 2024Life Safety
    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 19.2.10.1; 7.10.5Exit Signage
    • 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
    Confirmed that previously cited deficiencies were corrected and no new noncompliance was found. All surveyed regulations were met.
    03 Jun 2024Revisit
    Concluded all previous deficiencies corrected and no new noncompliance found.
    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
    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
    Found no deficiencies identified during a complaint survey conducted January 11, 2024.
    09 Nov 2023Complaint
    Found no deficiencies related to the complaint investigation.
    14 Sept 2023Revisit
    Verified no deficiencies were found during the follow-up visit; all previously cited deficiencies were corrected.
    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
    • 483.12(c)(2)-(4)Investigate/Prevent/Correct Alleged Violation
    20 Jul 2023Complaint
    Investigated a complaint intake and found no deficiencies related to the complaints.
    06 Jul 2023Revisit
    Verified that all prior deficiencies were corrected and no new noncompliance was found.
    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
    Found no deficiencies. Previous issues were corrected.
    22 May 2023Revisit
    Verified that all deficiencies were corrected and compliance with all requirements was achieved.
    18 May 2023Revisit
    Found no deficiencies; a follow-up visit confirmed compliance with all regulations surveyed.
    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
    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
    • §483.12(c)(2)-(4)Investigate/Prevent/Correct Alleged Violation
    23 Mar 2023Licensure
    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
    Found no deficiencies. The survey determined the facility was in compliance with state requirements.
    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
    • NFPA 101 2012; NFPA 96 2011Cooking facilities ventilation
    • NFPA 101 19.3.2.6; NFPA 30Alcohol-based hand rub storage
    • NFPA 101 19.3.4.1; NFPA 72 26.3.4.3Fire alarm system - testing and maintenance
    • NFPA 101 19.3.4.1; NFPA 9.6.1.6Fire alarm system - out of service
    • NFPA 101 19.3.5.1; NFPA 25 5.2.1.2Sprinkler system - installation
    • NFPA 101 11.1 and NFPA 70 314.25Utilities - Gas and electric
    • NFPA 101 19.7.1.6Fire drills
    • NFPA 101 19.7.4Smoking regulations
    • NFPA 101 19.7.6; NFPA 80 5.2.3Maintenance, inspection & testing - doors
    • NFPA 101 19.7.8; NFPA 18.7.8Portable space heaters
    • NFPA 101 9.1.2; NFPA 70 700.10; NFPA 110Electrical systems - essential electric system
    • NFPA 101 9.1.2; NFPA 70 400.8Electrical equipment - power cords and extension cords
    • NFPA 99 11.3; NFPA 99 11.3.2.6Gas equipment - cylinder and container storage
    • NFPA 99 11.7.3.2Gas equipment - liquid oxygen equipment
    02 Mar 2023Complaint
    Concluded that no deficiencies were identified during a complaint investigation conducted from 2023-03-01 to 2023-03-02.
    02 Feb 2023Revisit
    Verified no deficiencies were found on the follow-up visit; all prior deficiencies were corrected and compliance achieved.
    26 Jan 2023Revisit
    Verified that previously cited deficiencies were corrected and found no new noncompliance.
    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
    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
    Found no deficiencies. The complaint investigation concluded no deficiencies were identified.
    18 Jul 2022Revisit
    Found no deficiencies.
    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
    Concluded that prior deficiencies were corrected and compliance has been restored.
    01 Mar 2022Revisit
    Confirmed compliance following a follow-up survey; all prior deficiencies were corrected and no new noncompliance was found.
    01 Mar 2022Revisit
    Found all prior deficiencies corrected and no new noncompliance was found.
    01 Mar 2022Revisit
    Found no deficiencies.
    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
    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
    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
    • NFPA 101 Life Safety Code (2012 edition) - Egress DoorsEgress Doors
    • NFPA 101 Life Safety Code (2012 edition) - Doors with Self-Closing DevicesDoors with Self-Closing Devices
    • NFPA 101 2012 - Exit SignageExit Signage
    • NFPA 101 2012 - Hazardous Areas - EnclosureHazardous Areas - Enclosure
    • NFPA 101 2012; NFPA 96 - Cooking FacilitiesCooking Facilities
    • NFPA 13 - Sprinkler System InstallationSprinkler System - Installation
    • NFPA 80 - Fire Door Inspections; NFPA 101 Corridor - DoorsCorridor - Doors
    • NFPA 101 2012 - Fire DrillsFire Drills
    • NFPA 101 2012 - Combustible DecorationsCombustible Decorations
    09 Nov 2021Licensure
    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
    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
    Investigated a complaint and conducted a focused infection control survey; found no deficiencies.
    15 Apr 2021Complaint
    Found no deficiencies.
    29 Dec 2020Revisit
    Determined that all prior deficiencies were corrected and no new noncompliance was found.
    01 Dec 2020Revisit
    Concluded that all previously cited deficiencies were corrected and no new noncompliance found.
    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
    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
    Investigated a complaint and COVID-19 infection-control review; found no deficiencies.
    31 Mar 2020Complaint
    Investigated a complaint and conducted a focused infection control survey; found no deficiencies.
    10 Mar 2020Revisit
    Verified no deficiencies were found; all prior deficiencies were corrected.
    14 Feb 2020Life Safety
    Verified compliance with life safety code after a follow-up review; previous deficiencies were corrected.
    13 Feb 2020Complaint
    Investigated the complaint survey and found no deficiencies identified.
    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
    Determined the facility was in compliance with State requirements after a survey conducted January 6-9, 2020.
    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
    Investigated a complaint and found no deficiencies.
    17 Oct 2019Revisit
    Verified no deficiencies found after a follow-up review of prior findings.
    03 Oct 2019Complaint
    Investigated a complaint and found no deficiencies.
    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.
    • CFR 483.12(c)Reporting of Alleged Violations
    • CFR 483.12(c)(2)-(4)Investigate/Prevent/Correct Alleged Violation
    02 Apr 2019Revisit
    Verified that prior life safety deficiencies were corrected and compliance was restored.
    02 Apr 2019Revisit
    Concluded that all prior life safety deficiencies were corrected and compliance restored.
    19 Mar 2019Revisit
    Verified that all prior deficiencies were corrected and no new noncompliance was found.
    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
    • CFR 483.15(d)(2)Bed-Hold Notice Upon Transfer
    • CFR 483.20(b)(1)-(2)(i)-(iii)Comprehensive Assessments & Timing
    • CFR 483.20(g)Accuracy of Assessments
    • CFR 483.45(a)-(c)Pharmacy Services
    • CFR 483.45(d)Unnecessary Drugs
    • CFR 483.55(b)(1)-(5)Dental Services
    • CFR 483.60(i)(1)-(2)Food Safety
    10 Jan 2019Licensure
    Concluded compliance with state requirements; no deficiencies cited.
    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
    Found a potable water protection deficiency due to sink aerators; aerators in multiple rooms were removed.
    • WDH Chapter 3, Section 5(b)(iv)(E)Potable water protection – aerator removal requirement
    23 Aug 2018Complaint
    Investigated a complaint; found no deficiencies identified.
    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.
    • NFPA 101 8.4.6.2; NFPA 80 19.4.1.1Fire dampers testing/maintenance
    04 Apr 2018Revisit
    Found no deficiencies. A follow-up survey on 2018-04-04 concluded compliance with state requirements.
    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
    Verified compliance with all regulations; no new noncompliance found.
    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
    Found no deficiencies. All prior deficiencies were corrected and no new noncompliance was found.
    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
    The inspection identified multiple life-safety deficiencies related to egress doors, fire protection systems, emergency lighting, and power/electrical safety.
    • NFPA 101, 2012 Edition (Sections: 19.2.1; 19.7.*)Exit doors - improper locking
    • NFPA 101, 2012 Edition (Sections related to egress and timing of door unlocking)Delayed egress/egress doors – improper controls
    • NFPA 101, 2012 Edition (Emergency lighting and signage requirements)Emergency lighting/exit signage – maintenance
    • NFPA 101, 2012 Edition (Sprinkler System – Maintenance and Testing)Sprinkler system – maintenance/testing
    • NFPA 101, 2012 Edition (Portable Fire Extinguishers)Portable fire extinguishers – maintenance/placement
    • NFPA 101, 2012 Edition (Corridors/Doors)Corridor - Doors
    • NFPA 101, 2012 Edition (Fire Protection – Other)Fire protection – other
    • NFPA 101, 2012 Edition (Portable Space Heaters)Portable space heaters
    • NFPA 101, 2012 Edition (Essential Electric Systems)Electrical systems – essential electric system
    • NFPA 101, 2012 Edition (Fire protection – other)Fire protection – other
    • NFPA 101, 2012 Edition (Fire alarm system – Testing/maintenance)Fire alarm system – Testing and maintenance
    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
    Investigated the complaint and found no deficiencies.
    20 Oct 2017Revisit
    Concluded that all previous deficiencies were corrected and no new noncompliance found; in compliance with all regulations surveyed.
    04 Oct 2017Revisit
    Verified that previously cited deficiencies were corrected and no new noncompliance was found.
    04 Oct 2017Revisit
    Concluded that previous deficiencies were corrected and no new noncompliance was found.
    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
    Determined the operation was in compliance with State requirements. Found no deficiencies.
    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
    Investigated deficiencies related to regulatory compliance and safety during a health licensing review.
    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
    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.
    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
    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
    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
    Identified a deficiency in electrical safety due to panel boards not installed in accordance with NFPA 70.
    • NFPA 70Electrical: Panel boards
    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
    Determined substantial compliance with program requirements and rescinded the denial of payment for new admissions, enabling continued participation in Medicare/Medicaid.
    31 Jan 2017Revisit
    Completed corrections for six cited deficiencies. All corrective actions were completed as of the revisit date.
    • 483.10(g)(14)Code regulation 483.10(g)(14)
    • 483.12(a)(3)(4)(c)(1)-(4)Code regulation 483.12(a)(3)(4)(c)(1)-(4)
    • 483.10(i)(6)Code regulation 483.10(i)(6)
    • 483.24Code regulation 483.24
    • 483.60(i)(1)-(3)Code regulation 483.60(i)(1)-(3)
    • 483.90(h)(5)Code regulation 483.90(h)(5)
    31 Jan 2017Revisit
    Investigated deficiencies previously reported and found corrections completed.
    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
    Determined no deficiencies were found on the follow-up visit.
    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
    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
    Investigated deficiencies related to the facility environment and housekeeping. Observations and interviews showed inadequate temperature control and related maintenance issues affecting resident comfort.
    • Ch 11 Sec 6(a)(1) Physical EnvironmentPhysical Environment
    15 Dec 2016Complaint
    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 ANotify of changes (injury/decline/room, etc.)
    • Type AMisappropriation of resident property / abuse reporting
    • Type ATemperature/comfort and environmental controls
    • Type AContinued from page 16 – sanitation and safety practices
    • Type AStorage and sanitation – physical environment
    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
    Found no deficiencies during the revisit.
    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
    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
    Investigated a complaint via a survey conducted from 10/9/16 to 10/10/16. Found no deficiencies.
    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
    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
    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
    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
    Investigated the complaint and found no deficiencies.
    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
    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
    Verified prior deficiencies were corrected and no new violations identified.
    16 Mar 2016Revisit
    Verified prior deficiencies were corrected.
    • 483.20(k)(3)(i)
    • 483.25
    • 483.25(d)
    16 Mar 2016Revisit
    Verified corrections completed for two deficiencies previously cited in CMS-2567.
    • 483.13(c)
    • 483.25(c)
    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
    Verified that previously reported deficiencies were corrected and follow-up actions completed.
    16 Mar 2016Complaint
    Investigated the complaint intake and related survey; determined that no deficiencies were identified.
    10 Feb 2016Complaint
    Investigated a complaint and found deficiencies in wound care documentation and ongoing wound management.
    • Wound care documentation/assessment
    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
    Identified hot water temperatures above 110°F in multiple sinks during the visit.
    • Ch 11 Sec 6 (a)(v) Physical EnvironmentPhysical Environment
    15 Jan 2016Revisit
    Found deficiencies in diabetes monitoring/insulin administration, medication order audits, catheter management, and nurse staffing oversight.
    • Type ADiabetes management/insulin monitoring
    • Audit of medication and treatment orders; monitoring
    • Urinary catheter management and UTI prevention
    • Nurse staffing and compliance monitoring
    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 ANotice of Rights/Financial Resources
    • Type ARight to Prompt Efforts to Resolve Grievances
    • Type ATransfer/Discharge
    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
    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
    Found corrections completed for identified deficiencies and confirmed through follow-up.
    02 Dec 2015Complaint
    Investigated the complaint and found that no deficiencies were identified.
    02 Dec 2015Life Safety
    Investigated the complaint and found no deficiencies.
    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
    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
    Investigated a complaint from July 2015 and found no deficiencies.
    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
    Verified that corrective actions from earlier concerns were completed after a follow-up visit.
    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
    Investigated the complaint intake and found no deficiencies.
    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
    Determined that the facility was in compliance with state requirements after a multi-day survey.
    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
    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
    Investigated a follow-up after prior deficiencies and found that corrections were completed.
    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
    Identified no deficiencies after the post-certification revisit; corrections were completed.
    16 Apr 2015Revisit
    Investigated the prior deficiencies and confirmed correction of all cited items.
    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
    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
    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
    Found no deficiencies. The revisit indicated full compliance with applicable requirements.
    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
    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
    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
    Investigated infection-control practices and found a deficiency related to wound dressing changes.
    • 483.65Infection control
    01 Oct 2014Revisit
    Investigated and found infection control measures not adequately implemented, including improper wound dressing changes.
    • F-441Infection Control
    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
    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
    An investigation found multiple deficiencies in resident care, safety, infection control, and environmental management, with several pages detailing ongoing corrective actions.
    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
    Found no deficiencies; corrections completed during follow-up.
    21 Feb 2014Revisit
    Found no deficiencies cited after the revisit.
    11 Feb 2014Life Safety
    The investigation found multiple deficiencies related to egress door locking, separation of hazardous areas, fire drills, and building systems maintenance.
    • 2000 NFPA 101 Section 19.2.2.2.1; 7.2.1.5.1; 19.2.2.2.4Locking devices on egress doors
    • 2000 NFPA 101 Life Safety Code StandardHazardous areas separation in smoke compartments
    • 2000 NFPA 101 Life Safety Code StandardFire drills conducted quarterly on each shift
    • 2000 NFPA 101 Life Safety Code StandardMaintenance of heating, cooling and ventilation
    • 2000 NFPA 101 Life Safety Code StandardEmergency power systems / generator testing
    09 Jan 2014Complaint
    Investigated deficiencies found in meal service timing, care planning updates, infection control practices, and bowel management oversight.
    • Continued from page 2 – timely meals / resident care
    • Continued from page 8 – care plan updates / infection control
    • Continued from page 11 – resident mobility / safety
    • Continued from page 12 – bowel management documentation
    • Systematic changes – bowel management / monitoring audits
    09 Jan 2014Licensure
    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
    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
    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
    Found that one of three investigations was not thorough and complete, with insufficient interviews and documentation.
    • Investigate/Report Allegations/Individuals
    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
    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
    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
    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
    Investigated a follow-up after prior findings and confirmed corrections completed.
    • 483.25(h)
    • 483.30(e)
    • 483.75(f)
    08 Jun 2012Revisit
    Investigated a follow-up; found no deficiencies cited.
    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
    Investigated a complaint and found no deficiencies.
    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
    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
    Found no deficiencies.
    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
    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
    Identified deficiencies in care planning; care plans were not adequately developed with measurable goals and timelines.
    • Comprehensive care plans
    22 Sept 2011Licensure
    Concluded compliance with state requirements after a licensure survey conducted from 9/19/2011 to 9/22/2011.
    17 Aug 2011Revisit
    Verified corrections were completed and substantial compliance achieved after a follow-up visit.
    16 Jun 2011Complaint
    Investigated an allegation of abuse/neglect and found deficiencies in timely reporting and thorough investigation.
    • Type AFailure to report and thoroughly investigate abuse/neglect
    • Type AAudit of incidents and reporting/investigation patterns
    18 Jan 2011Revisit
    Verified that previously reported deficiencies were corrected during the follow-up visit.
    07 Jan 2011Revisit
    Investigated the complaint and found no deficiencies.
    18 Nov 2010Licensure
    Identified that the dietary manager did not meet the required qualifications.
    • SNH Section 11Dietary manager qualifications
    18 Nov 2010Complaint
    Investigated an allegation of deficiencies and found multiple issues in resident care, safety, and documentation.
    • Type AContinued From page 1
    • Type AMonitoring
    • Type ACorrective Action
    • Type ACross-reference to corrective actions
    18 Nov 2010Revisit
    Concluded substantial compliance following the revisit; prior deficiencies were corrected.
    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
    Investigated the complaint; found no deficiencies.
    14 May 2010Complaint
    Investigated a complaint and found no deficiencies identified.
    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
    Investigated deficiencies from a prior visit; corrections were completed.
    02 Dec 2009Revisit
    Concluded that corrections from a prior survey were completed; no deficiencies were cited on this revisit.
    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
    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
    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
    Investigated a complaint and found no deficient practices identified.
    20 Feb 2009Complaint
    Investigated a complaint; no deficiencies identified.
    29 Oct 2008Revisit
    Investigated deficiencies; multiple regulatory violations were cited and subsequently corrected.
    29 Oct 2008Revisit
    Investigated prior deficiencies and confirmed corrective actions were completed.
    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
    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
    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
    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
    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
    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
    • 483.20, 483.20(b)Comprehensive Assessments
    • 483.20(c) Quarterly Review AssessmentsQuarterly Review Assessments
    25 Jan 2008Revisit
    Verified corrections completed for previously cited deficiencies.
    • 483.12(a)(4)-(6)483.12(a)(4)-(6) Life Safety Code
    25 Jan 2008Revisit
    Verified corrections from the prior survey were completed.
    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
    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
    Verified corrections were completed for previously cited deficiencies.
    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
    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
    Investigated a complaint and found no deficiencies identified.
    20 Apr 2007Complaint
    Investigated a complaint and found no deficiencies.
    21 Nov 2006Complaint
    Found no deficiencies identified in two complaint investigations.
    21 Nov 2006Complaint
    Investigated two complaint investigations conducted; found no deficiencies identified.
    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
    Verified corrections addressed previously cited deficiencies; no uncorrected deficiencies remained.
    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
    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
    • 483.15(e)(1)Accommodation of needs
    • 483.20(e)(1)Resident assessment
    • 483.20(b)(2)(ii)Resident assessment – significant change
    • 483.20(g)-(j)Resident assessment – continued deficiencies
    • 483.25Quality of care
    06 Apr 2006Licensure
    Identified deficiencies across several areas, including resident assessments, cleanliness and maintenance, daily living support, infection control, and medication labeling.
    • 483.20(b)(2)COMPREHENSIVE ASSESSMENTS
    • 483.25(h)(2)HOUSEKEEPING/MAINTENANCE
    • 483.20(d)(2)(ii)RESIDENT ASSESSMENT (WHEN REQUIRED)
    • 483.25(k)ACTIVITIES OF DAILY LIVING
    • 483.25(c)PRESSURE SORES
    • 483.60(c)FREQUENCY OF PHYSICIAN VISITS
    • 483.80LABELING OF DRUGS AND BIOLOGICALS
    • 483.65(c)INFECTION CONTROL - LINENS
    07 Mar 2006Life Safety
    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
    Found no deficiencies after two complaint investigations.
    10 Jan 2006Complaint
    Investigated two complaints and found no deficiencies.
    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
    Investigated the complaint survey; found no deficiencies identified.
    06 Apr 2005Revisit
    Verified corrections were completed and compliance achieved.
    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
    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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