I volunteered here all summer and am very pleased - the OT and staff (Marsha, Denise, Brook, Susan and the cheerful receptionist) are kind, efficient and genuinely care. My mother felt at home: clean rooms, good food, excellent memory care and residents thriving; I highly recommend.
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
3.27·(33)
Overall rating
5
4
3
2
1
Care
2.2
Staff
3.2
Meals
2.5
Amenities
1.0
Value
1.0
Pros
Compassionate, attentive caregiving staff
Skilled rehabilitation and therapy services
Supportive memory-care programming
Clean and comfortable resident rooms
Pleasant, home-style dining options
Engaging activities with easy scheduling
Welcoming reception and family-oriented interactions
Active volunteer and community involvement
Cons
Inconsistent staffing levels and shift coverage
Inconsistent medication administration and tracking
Slow response to resident call lights and care requests
Gaps in personal-care and wound-management practices
Poor family communication and care-transition coordination
Policies prioritizing administrative/financial constraints over individualized care
Uneven care quality across different units and shifts
Dated physical plant and environmental-control issues
Allegations of staff theft and financial misconduct
Summary of reviews
The reviews present a mixed picture of Shepherd of the Valley Rehabilitation and Wellness. Many families and visitors highlight clearly positive experiences: individual caregivers who are compassionate and attentive, therapists and rehabilitation staff who produce measurable improvements, and a memory-care unit and activity program that residents and performers enjoy. Several reviewers specifically praised friendly front-desk staff, engaged occupational and physical therapists, clean resident rooms, and satisfying meals. Volunteer and community involvement also appears to be a strength in supporting resident engagement.
At the same time, recurring operational concerns emerge across multiple accounts. Staffing variability and apparent shortages are a frequent theme and are linked to slow responses to call lights, delays in attending to personal-care needs (including bathing and wound management), and inconsistent medication administration and documentation. A number of reviewers described missed or delayed medications and difficulties in ensuring timely clinical care, including pain-management issues at end of life. These items suggest gaps in clinical workflows and medication-tracking processes rather than isolated interpersonal shortcomings.
Staff behavior and consistency are described unevenly. Numerous individual staff members received strong praise for kindness, efficiency, and attentiveness; however, other accounts indicate concerns about staff conduct, responsiveness, and communication tone toward families. There are also references to perceived inconsistency between units and shifts, and some families reported frequent room reassignments or inconsistent roommate matching. A small number of reviewers raised serious allegations—including theft and instances where staff appeared to act beyond prescribed clinical orders—that would merit follow-up by oversight authorities.
Dining and activities receive generally favorable comments from families who experienced good food quality and well-run programming; performers and volunteers also described positive interactions, particularly in memory-care areas. Conversely, other reviewers described lower food quality and an overall atmosphere they found upsetting, reinforcing the pattern of uneven experience across the facility.
Facility and management issues recur in the feedback. While parts of the building and some rooms are described as clean and comfortable, other areas were characterized as dated and subject to environmental-control problems such as heating. Several families described restrictive administrative policies (for example, therapy cutoffs or limitations on leave) and poor communication about care transitions or placement changes. These management-level traits—perceived prioritization of administrative/financial constraints, inadequate family communication processes, and inconsistent operational oversight—appear to influence the variability in care experience.
Overall, the facility shows clear strengths in personal relationships, therapy services, and activity programming, but also consistent operational weaknesses that can materially affect resident experience and safety. Prospective residents and families should weigh these mixed patterns carefully, observe staffing on different shifts, ask specific questions about medication administration, wound care protocols, and end-of-life procedures, and seek clarity on unit-to-unit differences before making placement decisions.
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Medicare Ratings
1·/ 5
Cited by CMS for abuse, or potential for abuse, on its most recent survey cycle.
Overall
Health Inspection
Staffing
Quality Measures
Ratings from the U.S. Centers for Medicare & Medicaid Services (Care Compare). View on Medicare.gov
Location
Shepherd of the Valley Rehabilitation and Wellness is located at 60 Magnolia, Casper, WY, 82604.
About Shepherd of the Valley Rehabilitation and Wellness
Shepherd of the Valley Rehabilitation and Wellness has been providing care for over 100 years, and you'll find it takes Medicaid and Medicare, which makes things easier for many families, and it stands as a nonprofit community supported by the Evangelical Lutheran Church of America and part of the EmpRes family. The place accepts people who need skilled nursing, short-term rehabilitation, long-term care, assisted living, memory care for Alzheimer's and dementia, post-acute care, respite care, hospice, and even offers independent retirement living and adult day care. Residents benefit from personalized care plans and a wide range of therapies, like physical, occupational, respiratory, hydration, and speech and language therapy, with recovery services to help regain strength and quality of life and audiology solutions for those with hearing needs, while memory care services come with special cognitive activities and secure units. Daily activities and community-sponsored events keep everyone involved, while resident-run programs help folks feel right at home, plus there's a library, a game room, fitness and wellness/spa rooms, a community garden, outdoor walking paths, cable TV, high-speed Wi-Fi, kitchenette options in rooms, and both private bathrooms and furnished rooms available, so comfort isn't hard to come by. They've got air conditioning, telephones, laundry and linen services, regular housekeeping, professional meal preparation that takes allergies and diabetes into account, and transportation to get residents where they need to go, so everyday needs are taken care of with a warm touch, and if folks need help with bathing, dressing, or getting around, staff assist with daily activities, with a 24-hour call system in place for emergencies, so help's never far away. For new residents, the concierge service and move-in coordination make arrival a little less stressful, and wheelchair accessibility is there throughout the facility. While there's a licensed capacity of 192 certified beds and an average census of about 156 residents per day, nurse staffing runs at 3.18 hours per resident daily, which is less than the state average but the nurse turnover rate is lower than most places, though management and ownership include Couve Financial Services LLC and Pacific Northwest Opco Management LLC, and the facility has had some violations, mainly in infection control and drug labeling/storage, with deficiencies in meeting all resident activity needs, which are concerns families may want to consider. Staff includes a dedicated professional team offering constant supervision for those who need it, plus recovery and wellness programs that follow a holistic approach for everyone trying to move from hospital to home, so you'll see both short-term rehabilitation and long-term support under one roof, with amenities that give a sense of comfort and promote social engagement. The main goal remains to give each resident a supportive, empowering place to live, where residents can feel safe, cared for, and encouraged to take part in daily life as much as possible.
People often ask...
Shepherd of the Valley Rehabilitation and Wellness offers assisted living, memory care, and skilled nursing.
There are 1 photos of Shepherd of the Valley Rehabilitation and Wellness on Mirador.
The full address for this community is 60 Magnolia, Casper, WY 82604.
No, Shepherd of the Valley Rehabilitation and Wellness 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-186
Facility type
Nursing Home
Inspection Reports
220
Reports
48
Type A Citations
2
Type B Citations
135
Complaints
21
Years
22 May 2025Complaint
22 May 2025Complaint
Investigated a complaint about resident-to-resident abuse and found a failure to protect a resident from physical abuse by another resident, resulting in harm.
42 CFR 483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
22 May 2025Complaint
22 May 2025Complaint
Investigated a complaint about resident-to-resident abuse; found a resident punched another, causing a bloody nose, with safeguards implemented afterward.
CFR 483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
22 May 2025Revisit
22 May 2025Revisit
Verified compliance with all regulations. All previously cited deficiencies were corrected and no new noncompliance was found.
20 Mar 2025Complaint
20 Mar 2025Complaint
Identified deficiencies in notifying physicians of changes in condition, providing quality of care, and preventing pressure ulcers, leading to harm for multiple residents.
Type A§483.10(g)(14)Notify of Changes
Type A§483.25Quality of care
Type A§483.25(b)(1)(i)-(ii)Treatment/Services to Prevent or Heal Pressure Ulcers
23 Dec 2024Revisit
23 Dec 2024Revisit
Verified compliance after a revisit; all prior deficiencies were corrected and no new noncompliance was found.
17 Dec 2024Revisit
17 Dec 2024Revisit
Verified that prior deficiencies were corrected and current safety requirements are met.
31 Oct 2024Complaint
31 Oct 2024Complaint
Found multiple deficiencies: restorative nursing not provided, activities not aligned with residents' interests, insufficient staffing, improper psychotropic medication management, unlabeled opened medications, bathing documentation issues, and lapses in infection control.
§483.24(a)Activities of daily living
§483.24(c)(1)Activities
§483.35(a)(1)(2)Sufficient Staffing
§483.45(e)Psychotropic Drugs
§483.45(g)(h)Labeling/Storage of Drugs
§483.70(h)Medical Records
§483.80(a)Infection Prevention and Control
31 Oct 2024Licensure
31 Oct 2024Licensure
Found no deficiencies. Confirmed compliance with state requirements.
29 Oct 2024Life Safety
29 Oct 2024Life Safety
Found multiple life safety code deficiencies, including hazardous-area enclosure issues, incomplete fire alarm testing documentation, smoke barrier gaps, missing fire-door closures, unrecorded fire-door inspections, and undocumented electrical system testing.
2012 NFPA 101, 19.3.2.1.2; 8.4Hazardous Areas - Enclosure
2012 NFPA 101, 19.3.4.1, 9.6.1.3; 2010 NFPA 72, Table 14.4.5, A.14.6.2.4 (7.14)Fire Alarm System - Testing and Maintenance
2012 NFPA 101, 19.3.2.5.3, 19.3.7.3, 8.5Subdivision of Building Spaces - Smoke Barrier
2012 NFPA 99, Ch.10, 4.4.1.2Electrical Systems - Essential Electric System
22 Oct 2024Revisit
22 Oct 2024Revisit
Concluded that all prior deficiencies were corrected and no new noncompliance was found.
07 Oct 2024Revisit
07 Oct 2024Revisit
Verified compliance after a follow-up visit; all previously cited deficiencies were corrected and no new noncompliance found.
10 Sept 2024Complaint
10 Sept 2024Complaint
Investigated a complaint alleging resident-to-resident abuse and safety concerns; found that one resident was punched by another, and care planning did not address the associated aggression.
483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
483.21(b)(1)(3)Comprehensive Care Plans
15 Aug 2024Complaint
15 Aug 2024Complaint
Found deficiencies in infection prevention and control related to testing and management of residents with acute respiratory symptoms, including failure to test symptomatic individuals and inconsistencies in following testing protocols.
42 CFR 483.80Infection Prevention & Control
12 Jun 2024Revisit
12 Jun 2024Revisit
Verified that prior deficiencies were corrected and no new noncompliance was found.
12 Jun 2024Revisit
12 Jun 2024Revisit
Found no deficiencies; all previously noted deficiencies were corrected.
25 Apr 2024Complaint
25 Apr 2024Complaint
Investigated a complaint and found no deficiencies.
22 Mar 2024Complaint
22 Mar 2024Complaint
Found failure to ensure timely assessment and treatment for a change of condition for one resident, resulting in hospital transfer and death.
CFR 483.25Quality of care
01 Feb 2024Complaint
01 Feb 2024Complaint
Investigated found misappropriation of a resident's funds from the medication cart; money was missing and later partially reimbursed. Safeguards and monitoring were reviewed following the incident.
CFR 483.12Freedom from misappropriation of resident property
14 Dec 2023Complaint
14 Dec 2023Complaint
Found no deficiencies.
14 Dec 2023Revisit
14 Dec 2023Revisit
Confirmed no deficiencies cited; prior findings were resolved.
09 Nov 2023Complaint
09 Nov 2023Complaint
Found failures to develop and implement comprehensive care plans for two residents, leaving edema/skin issues, wounds, and IV therapies unaddressed in their plans.
42 CFR 483.21(b)(1)Develop/Implement Comprehensive Care Plan
06 Oct 2023Revisit
06 Oct 2023Revisit
Verified compliance following a Life Safety Code revisit; all prior deficiencies were corrected and no new noncompliance was found.
06 Oct 2023Revisit
06 Oct 2023Revisit
Concluded that all deficiencies were corrected and compliance was achieved.
03 Oct 2023Revisit
03 Oct 2023Revisit
Verified that all previously cited deficiencies were corrected and no new noncompliance was found.
10 Aug 2023Complaint
10 Aug 2023Complaint
Regulators identified multiple deficiencies across medication self-administration, care planning, diabetes management, mobility, safety, oxygen use, dietary management, infection control, call systems, and wound care.
483.80(a)(1)-(4); 483.80(e); 483.80(f)Infection Prevention & Control
483.90(g)(1)-(2)Resident Call System
10 Aug 2023Licensure
10 Aug 2023Licensure
Found no deficiencies after a licensure survey conducted August 7-10, 2023.
09 Aug 2023Life Safety
09 Aug 2023Life Safety
Identified multiple life safety and fire protection deficiencies, including ceiling tiles, egress doors, exit signage, fire alarm testing records, sprinkler installations/maintenance, and oxygen cylinder storage.
NFPA 101 (2012) 19.1.1.1.3, 4.6.12.1General Requirements - Other
NFPA 72 (2010); NFPA 70Fire Alarm System - Testing and Maintenance
NFPA 13 (2012) 19.3.5.1; 6.2.7.1Sprinkler System - Installation
NFPA 25 (2011) 5.2.3.1Sprinkler System - Maintenance and Testing
NFPA 99 (2012) 5.1.3.2.3Gas and Vacuum Piped Systems - Central Supply
09 Aug 2023Life Safety
09 Aug 2023Life Safety
Found a bathroom hand sink water temperature exceeding regulatory limits (over 119°F) in room 133; corrective actions were initiated and ongoing audits planned.
Verified all previously cited deficiencies were corrected and no new noncompliance was found.
18 May 2023Complaint
18 May 2023Complaint
Investigated complaints found failures to address a resident's edema and to ensure safe lift transfers, with harm involved.
Type ACFR 483.25Quality of care
CFR 483.25(d)Accidents
03 May 2023Complaint
03 May 2023Complaint
Investigated complaint allegations and found no deficiencies. No violations were identified.
16 Mar 2023Complaint
16 Mar 2023Complaint
Investigated the complaint; found no deficiencies identified.
08 Feb 2023Complaint
08 Feb 2023Complaint
Found no deficiencies.
31 Jan 2023Complaint
31 Jan 2023Complaint
Investigated the complaint and found no deficiencies identified related to the complaint.
23 Dec 2022Revisit
23 Dec 2022Revisit
Confirmed compliance with federal requirements after a follow-up survey; no deficiencies were identified.
02 Nov 2022Revisit
02 Nov 2022Revisit
Found no deficiencies; previous issues were corrected and compliance was confirmed.
02 Nov 2022Revisit
02 Nov 2022Revisit
Verified that all deficiencies were corrected and compliance with requirements was restored.
26 Oct 2022Complaint
26 Oct 2022Complaint
Found infection control measures not followed during isolation precautions, with PPE not used as required and masks not changed when leaving isolation.
§483.80 Infection ControlInfection Prevention & Control
24 Oct 2022Revisit
24 Oct 2022Revisit
Verified prior deficiencies were corrected and found no new noncompliance.
31 Aug 2022Life Safety
31 Aug 2022Life Safety
Found multiple life-safety and emergency preparedness deficiencies, including generator testing gaps, door and barrier maintenance, hazardous area protections, and improper storage and maintenance of fire protection systems and equipment.
Type A42 CFR 483.73(e); 42 CFR 482.15(e); NFPA 110Emergency generator inspection and testing
Type ANFPA 101, 2012 edition, 19.2.2.2.1; 7.2.1.7(1)Means of Egress - General
Type ANFPA 101, 2012 edition, 19.2.2.2.4(2); 7.2.1.6.1.1(4)Egress Doors
Type ANFPA 101, 2012 edition, 19.2.2.2.1; 7.2.1.8Doors with Self-Closing Devices
Type ANFPA 101, 2012 edition, 19.2.2.5; 7.2.4.3Protection - Other
Type ANFPA 101, 2012 edition, 19.3.2; 19.3.5.9Hazardous Areas - Enclosure
Type ANFPA 101, 2012 edition, 19.3.2.5.5; NFPA 96, 12.1.2.3Cooking Facilities
Type ANFPA 101, 2012 edition, 19.3.2.6(8); NFPA 30, 9.7.1; NFPA 701Alcohol Based Hand Rub Dispenser
Type ANFPA 70; NFPA 72; NFPA 101 9.6.1.3; 2010 NFPA 72 Table 14.3.1(3)(d)Fire Alarm System - Testing and Maintenance
Type ANFPA 13, 6.2.7.1; NFPA 25, 5.2.1.2; NFPA 101 19.3.5.1; 9.7.5Sprinkler System - Installation
Type ANFPA 101, 19.3.5.1.2; NFPA 10, 7.3.1.2.1; NFPA 101, 9.7.4.1; NFPA 30, 9.7.2; NFPA 701Portable Fire Extinguishers
Type ANFPA 54; NFPA 70; NFPA 101 19.5.1.1; 9.1.2Utilities - Gas and Electric
Type ANFPA 101 19.7.5.6(1); 19.7.5.6(4)(c)Combustible Decorations
Type ANFPA 101 21.5.1.1; 9.1.3.1; NFPA 110 8.3.7.1Electrical Systems - Essential Electric System
Type ANFPA 101 19.5.1.2; NFPA 70 210.8(B)(5)Electrical Equipment - Other
31 Aug 2022Life Safety
31 Aug 2022Life Safety
Observed combustible storage in the boiler room, including ventilation filters and four snowblowers, violating fire-safety rules.
2006 International Fire Code 315.2.3Boiler room free of combustible storage
31 Aug 2022Licensure
31 Aug 2022Licensure
Investigated deficiencies found in resident assessments, care planning, restorative services, medication management, staff qualifications, and infection control.
42 CFR 483.20(b)(2)(ii)Comprehensive Assessment After Significant Change
42 CFR 483.21(b)(1); 42 CFR 483.21(b)(2)(iii)Develop/Implement Comprehensive Care Plan
42 CFR 483.21(b)(2)(i)-(iii)Care Plan Timing and Revision
42 CFR 483.24(a)(1)-(5); 42 CFR 483.24(b)(1)-(5)Activities Daily Living (ADLs)/Maintaining Abilities
42 CFR 483.45(g)-(h); 42 CFR 483.45(h)(1)-(2)Label/Store Drugs and Biologicals
42 CFR 483.70(f)Staff Qualifications
42 CFR 483.80(a)-(f) and 483.80(e)Infection Prevention & Control
23 Jun 2022Revisit
23 Jun 2022Revisit
Verified no deficiencies found and prior deficiencies corrected. Concluded compliance with all regulations surveyed.
04 May 2022Complaint
04 May 2022Complaint
Identified insufficient direct-care staffing on the East unit, with multiple days showing only 1-2 CNAs scheduled and on duty, risking resident care.
CFR 483.40(a)(1)(2)Sufficient/Competent Staff-Behavioral Health Needs
22 Mar 2022Revisit
22 Mar 2022Revisit
Found no deficiencies after a follow-up visit; all prior deficiencies were corrected and no new noncompliance was found.
22 Mar 2022Revisit
22 Mar 2022Revisit
Verified all prior deficiencies were corrected and no new noncompliance was found.
10 Feb 2022Complaint
10 Feb 2022Complaint
Investigated an infection control issue and found failures to follow transmission-based precautions and hand hygiene, risking spread of infection.
CFR 483.80Infection Prevention & Control
29 Dec 2021Complaint
29 Dec 2021Complaint
Investigated a complaint and identified safety and care planning deficiencies related to abuse prevention and delayed medical notification for changes in condition.
42 CFR 483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
42 CFR 483.21(b)(3)(i)Comprehensive Care Plans
19 Oct 2021Revisit
19 Oct 2021Revisit
Verified prior deficiencies were corrected and confirmed ongoing compliance.
17 Sept 2021Revisit
17 Sept 2021Revisit
Verified prior deficiencies were corrected and found no new noncompliance.
05 Aug 2021Life Safety
05 Aug 2021Life Safety
Identified several life safety deficiencies during the survey, including issues with egress surface elevation, self-closing doors, hazardous area enclosure, and sprinkler system maintenance.
NFPA 101, 19.2.1; 7.1.6.2Means of Egress - General
NFPA 101, 19.3.2.1; 19.3.5.9Hazardous Areas - Enclosure
NFPA 13, 2010; 6.2.6.2.1; 6.2.6.2.2; 6.2.7.1Sprinkler System - Installation
29 Jul 2021Licensure
29 Jul 2021Licensure
Found deficiencies in visitation practices, potential restraints, psychotropic medication management, and infection control. The findings showed restricted visitation, recliners not evaluated as restraints, missing rationales for dose reductions, and improper hand hygiene/PPE usage.
42 CFR 483.10(f)(4); 42 CFR 483.10(f)(4)(ii)-(v)Resident's right to receive/deny visitors
42 CFR 483.10(e); 42 CFR 483.12(a)(2)Right to be free from physical restraints
42 CFR 483.45Free from unnecessary psychotropic meds/PRN use
42 CFR 483.80Infection Prevention & Control
29 Jul 2021Licensure
29 Jul 2021Licensure
Found no deficiencies. The survey determined compliance with state requirements.
08 Jul 2021Complaint
08 Jul 2021Complaint
Found no deficiencies identified during the complaint investigation and the COVID-19 focused infection control survey.
30 Mar 2021Complaint
30 Mar 2021Complaint
Found no deficiencies identified during the complaint and COVID-19 focused infection control reviews.
12 Mar 2021Revisit
12 Mar 2021Revisit
Verified compliance with all regulations surveyed.
24 Feb 2021Revisit
24 Feb 2021Revisit
Verified deficiencies corrected and compliance restored.
28 Jan 2021Licensure
28 Jan 2021Licensure
Found deficiencies in PASARR screening and in post-fall neurological evaluations. These issues related to assessment compliance and resident safety procedures.
483.20(k)(1)-(3)Preadmission Screening for MD & ID
483.25Quality of care
28 Jan 2021Licensure
28 Jan 2021Licensure
Found no deficiencies. The survey concluded compliance with state requirements.
27 Jan 2021Life Safety
27 Jan 2021Life Safety
Found deficiencies in keeping fire doors properly closed and in securing oxygen cylinders.
2012 NFPA 99, Section: 11.6.2.3Gas Equipment - Precautions for Handling Oxygen Cylinders and Manifolds
06 Jan 2021Revisit
06 Jan 2021Revisit
Found all previously cited deficiencies corrected and no new noncompliance identified.
06 Jan 2021Revisit
06 Jan 2021Revisit
Found no deficiencies; prior deficiencies were corrected and no new noncompliance was found.
24 Nov 2020Licensure
24 Nov 2020Licensure
Determined that no deficiencies were identified during a COVID-19 focused infection control survey conducted on 11/23/20 through 11/24/20.
06 Nov 2020Complaint
06 Nov 2020Complaint
Identified deficiencies related to visitor rights, wound care, staffing, and infection prevention during a complaint and COVID-19 focused survey. Complications included failure to offer compassionate care visits, inadequate wound measurement, insufficient staffing, and unsafe infection control practices.
CFR 483.10(f)(4)Right to Receive/Deny Visitors
CFR 483.25Quality of care
CFR 483.35Sufficient Staff
CFR 483.80Infection Prevention & Control
12 Oct 2020Complaint
12 Oct 2020Complaint
Found multiple deficiencies across resident rights, self-determination, quality of care, safety, infection control, diet, laboratory notifications, and emergency equipment.
CFR 483.10Resident Rights
CFR 483.10Self-Determination
CFR 483.25Quality of Care
CFR 483.25Accidents
CFR 483.50(a)(2)Lab Services
CFR 483.60Dietary Needs
CFR 483.80Infection Prevention & Control
CFR 483.90Equipment Maintenance
04 Sept 2020Revisit
04 Sept 2020Revisit
Found no deficiencies; prior issues were addressed and compliance was confirmed.
01 May 2020Licensure
01 May 2020Licensure
Found no deficiencies.
31 Mar 2020Licensure
31 Mar 2020Licensure
Concluded that no deficiencies were identified in the COVID-19 focused infection control assessment.
13 Mar 2020Life Safety
13 Mar 2020Life Safety
Verified prior life safety code deficiencies were corrected and compliance was reestablished.
31 Jan 2020Complaint
31 Jan 2020Complaint
Identified multiple deficiencies across assessment accuracy, dementia care, medication management, activities, nutrition, and infection control.
Determined that the facility was in compliance with state requirements.
29 Jan 2020Life Safety
29 Jan 2020Life Safety
Identified multiple life safety deficiencies, including obstructed means of egress, improper egress doors, sprinkler head obstructions/missing escutcheons, and unsafe electrical practices.
NFPA 101 2012, 19.7.3.1; 7.1.10.1Means of Egress - General
NFPA 101 2012, 19.3.5.1; 9.7.5; NFPA 25 2011, 5.2.1.2Sprinkler System - Maintenance and Testing
NFPA 101 2012, 9.1.2; NFPA 70 2011, 110-26Utilities - Gas and Electric
NFPA 101 2012, 19.5.1.1; 9.1.2; NFPA 99 2012, 10.2.4; NFPA 70 2011, 400-8Electrical Equipment - Power Cords and Extension Cords
29 Jan 2020Life Safety
29 Jan 2020Life Safety
Found aerators on sink faucets at multiple locations, indicating inadequate protection of potable water. The finding was cited as a deficiency.
WDH Chapter 3 Section 5 (b)(iv)(E)Potable water protection
29 Jan 2020Licensure
29 Jan 2020Licensure
Determined all requirements were met during the survey.
21 Jan 2020Revisit
21 Jan 2020Revisit
Follow-up visit found all previously cited deficiencies corrected and no new noncompliance identified.
21 Jan 2020Revisit
21 Jan 2020Revisit
Verified that prior deficiencies were corrected and no new noncompliance was found.
21 Jan 2020Revisit
21 Jan 2020Revisit
Verified that previously cited deficiencies were corrected and found no new noncompliance. All regulations surveyed were in compliance.
13 Dec 2019Complaint
13 Dec 2019Complaint
Investigated a complaint and found neglect due to an improper wheelchair restraint during transport causing injury, and inadequate fall prevention resulting in a fracture after admission.
CFR 483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
CFR 483.25(d)(1)-(2)Free of Accident Hazards/Supervision/Devices
10 Dec 2019Complaint
10 Dec 2019Complaint
Investigated a discharge planning case and found inadequate planning that risked unsafe discharge and lack of coordination for a resident; evidence showed missing referrals and insufficient documentation of post-discharge needs.
CFR 483.21(c)(1)-(ix)Discharge Planning Process
20 Nov 2019Complaint
20 Nov 2019Complaint
Identified safety concerns in medication management, including administering baclofen with opioids without proper assessment and administering doses earlier than scheduled without orders.
42 CFR 483.25Quality of care
42 CFR 483.45(f)(2)Residents are free of significant medication errors
04 Nov 2019Revisit
04 Nov 2019Revisit
Verified that all previous deficiencies were corrected and no new noncompliance was found.
16 Oct 2019Complaint
16 Oct 2019Complaint
Found no deficiencies. The complaint investigation concluded with no deficiencies identified.
27 Aug 2019Complaint
27 Aug 2019Complaint
Investigated a complaint alleging inadequate dignity, assessments, PASARR screening, continence care, and behavioral health services; multiple deficiencies were found related to resident rights, assessment accuracy, PASARR procedures, incontinence management, and behavior health care.
CFR 483.10(a)(1)-(2); 483.10(b)(1)-(2)Resident Rights
§483.20(g)Accuracy of Assessments
§483.20(k)(1)-(3)Preadmission Screening for Mental Disorder/Intellectual Disability (PASARR)
§483.25(e)(1)-(3)Bowel/Bladder Incontinence
§483.40Behavioral Health Services
25 Jul 2019Complaint
25 Jul 2019Complaint
Determined no deficiencies identified in the complaint investigation.
29 May 2019Complaint
29 May 2019Complaint
Investigated a complaint and found no deficiencies identified.
24 Apr 2019Revisit
24 Apr 2019Revisit
Confirmed that prior deficiencies were corrected and no new noncompliance was identified during the follow-up.
24 Apr 2019Revisit
24 Apr 2019Revisit
Verified compliance with all regulations surveyed following a revisit; prior deficiencies were corrected and no new noncompliance was found.
24 Apr 2019Revisit
24 Apr 2019Revisit
Verified compliance with all surveyed regulations. No deficiencies were found.
11 Apr 2019Complaint
11 Apr 2019Complaint
Investigated a complaint survey conducted from 04/03/2019 to 04/11/2019 and found no deficiencies.
25 Mar 2019Revisit
25 Mar 2019Revisit
Verified that all prior deficiencies were corrected and compliance was restored.
20 Mar 2019Complaint
20 Mar 2019Complaint
Investigated a complaint found failures to provide timely pain management for a resident with chronic pain, including missed doses and delays due to prescription and pharmacy issues.
CFR 483.25(k)Pain Management
05 Mar 2019Complaint
05 Mar 2019Complaint
Investigated a complaint and found that the resident's family was not notified about a significant change in condition or a need to alter treatment for one resident.
§483.10(g)(14)Notification of Changes
05 Mar 2019Revisit
05 Mar 2019Revisit
Verified all prior deficiencies were corrected on follow-up visit.
14 Feb 2019Complaint
14 Feb 2019Complaint
Investigated, identified multiple deficiencies across resident rights, assessments, care plans, nutrition, activities, staffing, medications, infection control, and food service practices.
CFR 483.10Resident Rights
CFR 483.20(b)(2)(ii)Comprehensive Assessment After Signifcant Chg
CFR 483.20(g)Accuracy of Assessments
CFR 483.20(k)(1)-(3)PASARR
CFR 483.21(b)(1)-(3)Care Plan
CFR 483.21(c)(2)Discharge Summary
CFR 483.24(c)Activities
CFR 483.25Quality of Care
CFR 483.25(g)Nutrition/Hydration
CFR 483.35Sufficient Staffing
CFR 483.45(c)Drug Regimen Review
CFR 483.45(e)Psychotropic Drugs
CFR 483.60(d)Food Appearance/Palatability
CFR 483.60(i)Food Safety
CFR 483.75(g)QAPI
CFR 483.80(a)-(a)(2)Infection Control
CFR 483.80(a)(3)Antibiotic Stewardship
14 Feb 2019Life Safety
14 Feb 2019Life Safety
The site had multiple life-safety deficiencies including obstructions to exits, inadequate emergency lighting, improper storage of hazardous materials, and issues with fire protection systems and smoking controls.
2012 NFPA 101, 19.2.1; 7.1.10.1; 7.1.10.2.1Means of egress obstructed; blankets over exit hardware
Found no deficiencies identified during the review. The findings indicated compliance with state requirements.
25 Jan 2019Complaint
25 Jan 2019Complaint
Investigated respiratory care documentation and oversight; identified deficiencies in recording CPAP/BiPAP and oxygen use and ensuring treatments are included in care plans.
—Respiratory care documentation
—Documentation of respiratory treatments
24 Jan 2019Revisit
24 Jan 2019Revisit
Verified previous deficiencies were corrected and no new noncompliance was found.
03 Jan 2019Revisit
03 Jan 2019Revisit
Verified that prior deficiencies were corrected and no new noncompliance was found.
18 Dec 2018Complaint
18 Dec 2018Complaint
Investigations into alleged abuse found insufficient 24-hour safety monitoring during an inquiry, and multiple narcotic medication administration issues were identified.
42 CFR 483.12(c)(2)-(4)Investigate/Prevent/Report Allegations of Abuse, Neglect, Exploitation, or Mistreatment
42 CFR 483.45Pharmacy Services; Procedures; Pharmacist; Records
08 Nov 2018Complaint
08 Nov 2018Complaint
Found no deficiencies.
30 Oct 2018Complaint
30 Oct 2018Complaint
Investigated a complaint alleging abuse and found a resident was not free from abuse and neglect.
CFR 483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
09 Oct 2018Complaint
09 Oct 2018Complaint
Investigated allegations of abuse and neglect; found four residents experienced abusive or neglectful incidents, including a resident being punched, a staff member spanking a resident, and injury from improper use of safety restraints during transport.
CFR 483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
27 Sept 2018Revisit
27 Sept 2018Revisit
Confirmed compliance after revisit; all prior deficiencies were corrected.
27 Sept 2018Revisit
27 Sept 2018Revisit
Found no deficiencies. All prior deficiencies were corrected, and no new noncompliance was found.
27 Sept 2018Revisit
27 Sept 2018Revisit
Found no deficiencies. A revisit confirmed that prior deficiencies were corrected.
22 Aug 2018Complaint
22 Aug 2018Complaint
Investigated constipation care deficiencies for one resident and found insufficient nursing staffing on two units, leading to delayed care and bathing disruptions.
42 CFR 483.25Quality of care
42 CFR 483.35(a)(1)-(2)Sufficient staffing
22 Aug 2018Revisit
22 Aug 2018Revisit
Investigated a resident care issue related to bowel management and staffing, identifying deficiencies in care delivery and staffing practices.
Type A§483.25(a)(1) and §483.25(a)(2); CFR 483.25Quality of care / Bowel management
§483.70(e) Staffing and supervisionNursing staffing and supervision
25 Jul 2018Complaint
25 Jul 2018Complaint
Observed deficiencies in resident monitoring and care planning, including failure to notify family of a change in condition, incomplete care plans for residents, and unsafe wound care and equipment practices.
483.15(c)(1)(ii)Continued From page 2
483.21(b)(2)(i)-(iii)Continued From page 4
483.25(b)(1)(i)(ii)Continued From page 6
20 Jun 2018Complaint
20 Jun 2018Complaint
Investigated a complaint about nursing staff sufficiency and catheter care; identified staffing shortages and planning gaps in meeting resident needs.
483.35(a)(1)(2)Sufficient Nursing Staff
483.35(a)(1)(2)Sufficient Nursing Staff
483.70(e)(1)Resident population
483.70(e)(2)Facility resources
483.70(e)(3)Facility risk assessment
29 May 2018Revisit
29 May 2018Revisit
Concluded that all previously cited deficiencies were corrected and no new noncompliance was found.
30 Mar 2018Complaint
30 Mar 2018Complaint
Identified deficiencies in bathing assistance, grievance information, and timely response to changes in a resident’s condition; violations were cited.
§483.10(j)(3)Grievances information provided to residents
—Bathing/Personal care scheduling
—Timely assessment and action for changes in resident condition
08 Mar 2018Complaint
08 Mar 2018Complaint
Investigated the complaint; found no deficiencies.
08 Mar 2018Complaint
08 Mar 2018Complaint
Investigated a complaint and found no deficiencies.
02 Feb 2018Revisit
02 Feb 2018Revisit
Verified all prior deficiencies were corrected and found no new noncompliance.
02 Feb 2018Revisit
02 Feb 2018Revisit
Concluded that all previously cited deficiencies were corrected and no new noncompliance was found.
01 Feb 2018Revisit
01 Feb 2018Revisit
Verified all prior deficiencies were corrected and no new noncompliance found.
01 Feb 2018Revisit
01 Feb 2018Revisit
Verified that prior deficiencies were corrected; no new noncompliance found and all regulations surveyed were met.
16 Nov 2017Complaint
16 Nov 2017Complaint
An investigation identified several deficiencies related to resident rights, quality of life, and monitoring of care processes, including bathing/personal care and grievance handling.
—Rights/Quality of Life
—Monitoring/Grievances
—Care/Well-Being
16 Nov 2017Licensure
16 Nov 2017Licensure
Identified unsafe hot water temperatures due to improper temperature control; temperatures exceeded 110 degrees F on multiple dates and were verified during a follow-up observation.
Investigated findings showed multiple life-safety deficiencies including issues with ramp handrails, hazardous area enclosures, corridor doors, smoking regulations, and oxygen equipment storage. Noted incomplete corrective actions and need for further remediation.
2012 NFPA 101 Life Safety Code, sections referenced in the reportInitial Comments
2012 NFPA 101 Life Safety CodeHazardous Areas - Enclosure
Found a life-safety deficiency relating to oxygen storage, with storage capacity exceeded and facilities not maintained per NFPA requirements.
NFPA requirements for oxygen storageGas Equipment - Liquid Oxygen Equipment
06 Jul 2017Revisit
06 Jul 2017Revisit
Concluded that compliance was restored after a follow-up visit addressing a prior complaint investigation.
24 May 2017Complaint
24 May 2017Complaint
Investigated a complaint; found no deficiencies.
05 May 2017Complaint
05 May 2017Complaint
Investigated a complaint and found safety deficiencies related to bed-rail use and overall safety practices, including inadequate risk assessment and staff training.
—Systemic Changes
—Bed Rails
15 Mar 2017Complaint
15 Mar 2017Complaint
The inspection found deficiencies in monitoring residents for changes in condition and in notifying residents’ representatives after incidents, with several residents not properly assessed or monitored.
483.24, 483.25Quality of life/Quality of care
483.24, 483.25(k)(VI)Provide care/services for highest well being
15 Mar 2017Complaint
15 Mar 2017Complaint
Investigated a prior complaint and concluded the facility was back in compliance after a follow-up visit.
19 Jan 2017Revisit
19 Jan 2017Revisit
Investigated follow-up of prior deficiencies; life safety code issues were corrected in January 2017.
NFPA 101 - Life Safety CodeLife Safety Code
NFPA 101 - Life Safety CodeLife Safety Code
10 Jan 2017Revisit
10 Jan 2017Revisit
Identified life-safety deficiencies related to handrails and railing installations; noted a time-limited waiver for compliance.
NFPA 101 Life Safety Code StandardNFPA 101 Life Safety Code Standard
NFPA 101 Life Safety Code StandardNFPA 101 Life Safety Code Standard
10 Jan 2017Revisit
10 Jan 2017Revisit
Verified that prior deficiencies were corrected; corrective actions completed in December 2016.
NFPALife Safety Code deficiency
IMCMechanical/Building Code deficiency
LSCLife Safety Code deficiency
09 Jan 2017Revisit
09 Jan 2017Revisit
Found deficiencies corrected and verified on follow-up.
483.15(c)(6)
483.15(h)(2)
483.20(d)(3); 483.10(k)(2)
483.20(l)(1) & (2)
483.20(l)(3)
483.25(c)
483.60(b); 483.60(d); 483.60(e)
483.60(a); 483.60(b)
483.70(h)
483.75(l)(i)(1)
29 Nov 2016Complaint
29 Nov 2016Complaint
Identified safety deficiencies related to securing residents with belts during transport and gaps in driver training.
—Restraint and safety belt use during transport
20 Oct 2016Complaint
20 Oct 2016Complaint
Investigated a complaint and found deficiencies related to housekeeping/maintenance and resident care procedures, with corrective actions planned.
Type A—Housekeeping & Maintenance Services
20 Oct 2016Licensure
20 Oct 2016Licensure
Found in compliance with state requirements; no deficiencies cited.
19 Oct 2016Life Safety
19 Oct 2016Life Safety
Found life-safety and electrical-code deficiencies, including non-compliant exit signage and issues with electrical occupancy, requiring corrective actions and ongoing monitoring.
NFPA 101 LIFE SAFETY CODE STANDARD (7.10)Exit signage and emergency lighting
NFPA 70 NATIONAL ELECTRICAL CODEElectrical occupancy/installation compliance
NFPA 101 LIFE SAFETY CODE STANDARDMonitoring (life-safety signage and related controls)
19 Oct 2016Life Safety
19 Oct 2016Life Safety
Investigated electrical safety deficiency; a GFI combination light switch was painted over and did not function.
IMC Life Safety – NFPA ElectricIMC Life Safety – NFPA Electric
12 Oct 2016Revisit
12 Oct 2016Revisit
Identified deficiencies related to resident rights and quality of care; corrections were completed.
483.10(f)(2)Resident rights
483.13(c)(1)(ii)-(iii), (c)(2)-(4)Quality of care
18 Aug 2016Complaint
18 Aug 2016Complaint
Found deficiencies in grievance handling and reporting of allegations; investigation documentation and state notification were incomplete.
—Right to Prompt Efforts to Resolve Grievances
—Investigate/Report Allegations/Individuals
22 Jan 2016Revisit
22 Jan 2016Revisit
Identified deficiencies and confirmed corrections during a follow-up visit. All required actions were completed.
483.25(h)Correction
483.30(a)Correction
22 Jan 2016Revisit
22 Jan 2016Revisit
Identified multiple deficiencies with corrections reviewed; some items were resolved during the revisit.
483.10(b)(2)Deficiency under 483.10(b)(2)
483.10(f)(1)Deficiency under 483.10(f)(1)
483.13(a)Deficiency under 483.13(a)
22 Jan 2016Revisit
22 Jan 2016Revisit
Verified that previously cited deficiencies were corrected.
22 Jan 2016Complaint
22 Jan 2016Complaint
Investigated the complaint and found no deficiencies.
03 Dec 2015Revisit
03 Dec 2015Revisit
Investigated the allegation and found no deficiencies. No violations were cited.
23 Oct 2015Life Safety
23 Oct 2015Life Safety
Identified multiple life-safety and maintenance deficiencies, including issues with medical gas storage, door hardware for egress, exit signage, and sprinkler-related components.
Type ANFPA 99; NFPA 101 Life Safety Code (2000 edition), Section 19.3.5.1Medical gas storage area not compliant
Type ANFPA 101 Life Safety Code (2000 edition), Sections related to means of egress and door hardwareDoor hardware/egress not compliant
Type ANFPA 101 Life Safety Code, Sections on Means of Egress and Exit SignageExit signage/egress identification
Type ANFPA 101 Life Safety Code, Sections 7.x; 19.x (exit signage and egress components)Exit and directional signage
Type ANFPA 101 Life Safety Code; NFPA 25/ NFPA 99 considerations for equipment/egressEgress/maintenance deficiencies (doors and egress features)
22 Oct 2015Complaint
22 Oct 2015Complaint
Investigated a complaint alleging resident rights and safety concerns; found multiple deficiencies in care delivery, rights protection, and facility maintenance.
—Continued From page 4 - restraints and safety
—Maintenance and housekeeping
—ADL care provided for dependent residents
22 Oct 2015Licensure
22 Oct 2015Licensure
Investigated and found that the hot water temperatures in resident areas were not maintained at 110 degrees Fahrenheit, and weekly checks did not register correct temperatures.
Type BCh 11 Sec 6 (a)(k)(v) Physical EnvironmentPhysical environment – water temperature in resident rooms (not exceeding 110°F)
22 Oct 2015Revisit
22 Oct 2015Revisit
Identified deficiencies related to staffing and resident care, with concerns about supervision and adherence to care plans.
—Care and supervision of residents (continued findings)
483.30(a)Sufficient 24-hour nursing staff per care plans
22 Oct 2015Complaint
22 Oct 2015Complaint
An investigation identified several deficiencies in resident care planning, supervision, and medication-related processes with multiple cited items across the pages.
—Continued deficiencies in care planning
—Interventions not fully implemented
27 Aug 2015Revisit
27 Aug 2015Revisit
Investigated a follow-up after a prior survey; a revisit was conducted on 2015-08-27 and the form shows minimal documented findings.
27 Aug 2015Complaint
27 Aug 2015Complaint
Investigated deficiencies related to resident supervision and safety, with noted staffing and care-practice concerns observed during the visit.
15 Jul 2015Complaint
15 Jul 2015Complaint
Investigated a complaint survey and found no deficiencies identified.
02 Jul 2015Complaint
02 Jul 2015Complaint
Investigated oxygen-management concerns. Found deficiencies in ensuring oxygen supply and adherence to oxygen use protocols.
—Oxygen usage and management
12 May 2015Complaint
12 May 2015Complaint
Investigated the complaint; found no deficiencies.
09 Apr 2015Revisit
09 Apr 2015Revisit
Investigated deficiencies cited during a revisit; corrections have been completed.
483.20(k)(3Xi)
483.25(c)
15 Jan 2015Complaint
15 Jan 2015Complaint
Found deficiencies in preventing and treating pressure ulcers, including an observed open wound and inadequate care planning.
—Nursing services / pressure ulcer prevention and treatment
—Preventing/Treating pressure ulcers
07 Nov 2014Revisit
07 Nov 2014Revisit
Found no deficiencies cited. Corrections were completed for all previously identified items.
07 Nov 2014Revisit
07 Nov 2014Revisit
Found no deficiencies. The revisit confirmed prior corrective actions were completed.
16 Oct 2014Revisit
16 Oct 2014Revisit
Investigated the follow-up to address previously reported deficiencies; corrections completed for all items observed.
07 Oct 2014Life Safety
07 Oct 2014Life Safety
Investigated safety and evacuation concerns; found deficiencies in exiting, door hardware, and related life-safety systems requiring action.
—Means of egress not maintained
—Exit doors accessibility/egress maintenance
—Emergency generators remote stop button
—Penetrations of smoke barriers
27 Aug 2014Life Safety
27 Aug 2014Life Safety
Investigated life-safety deficiencies affecting smoke-resistance, exit access, and door hardware, with multiple failures to meet required standards. Found issues across several areas related to ceilings, exits, and HVAC testing.
NFPA 101 Life Safety Code StandardCeiling smoke resistance in smoke compartments
NFPA 101 Life Safety Code StandardSmoke resistance of compartments
NFPA 101 Life Safety Code StandardExits readily accessible
NFPA 101 Life Safety Code StandardDoor hardware releasing mechanism
NFPA 90A Life Safety Code StandardHVAC system testing
27 Aug 2014Complaint
27 Aug 2014Complaint
Found multiple deficiencies related to unequal treatment of residents, lack of dignity and individuality, insufficient activities, and poor housekeeping/maintenance.
Type A483.12Equal Practices Regarding Payment Source
Type A483.15(a)Dignity and Respect of Individuality
Type A483.15(f)(1)Activities/Interests/Needs of Each Resident
Type A483.15(h)(2)Housekeeping and Maintenance Services
27 Aug 2014Life Safety
27 Aug 2014Life Safety
Investigated a deficiency related to emergency equipment and plumbing safety; observed that valves and emergency eyewash components did not meet standards.
NFPA 101 Life Safety Code; ANSI Z358.1NFPA 101 Miscellaneous Life Safety
27 Aug 2014Licensure
27 Aug 2014Licensure
Determined the provider was in substantial compliance with state requirements.
18 Mar 2014Revisit
18 Mar 2014Revisit
Cited deficiencies under resident rights; corrections completed.
483.60(b), (d), (e)Resident rights
18 Mar 2014Revisit
18 Mar 2014Revisit
Investigated uncorrected deficiencies from a prior survey during a follow-up visit.
07 Feb 2014Complaint
07 Feb 2014Complaint
Investigated the facility's control of narcotics and found deficiencies in maintaining a facility-wide system for tracking, reconciling, and detecting diversion.
—Drug Records, Label/Store Drugs & Biologicals
11 Dec 2013Complaint
11 Dec 2013Complaint
Found no deficiencies.
07 Nov 2013Revisit
07 Nov 2013Revisit
Found no deficiencies.
20 Jun 2013Licensure
20 Jun 2013Licensure
An inspection identified deficiencies in medication administration documentation and in the facility's infection control program, with multiple pages detailing required improvements and follow-up actions.
—
—
20 Jun 2013Licensure
20 Jun 2013Licensure
Identified deficiencies in medication administration, infection control, and quality assurance practices, with gaps in nursing supervision and environmental safety.
—Nursing Services
—Infection Control
—Facility environment
—Quality Assurance/Performance Improvement
20 Jun 2013Licensure
20 Jun 2013Licensure
Determined the provider was in compliance with state requirements after a licensure survey conducted June 17–20, 2013. Found no deficiencies.
18 Jun 2013Life Safety
18 Jun 2013Life Safety
The review identified several life-safety deficiencies, including issues with corridor door smoke resistance, sprinkler system components, electrical wiring, and irregular fire drills.
NFPA 101 Life Safety Code StandardCorridor doors smoke resistance
NFPA 101 Life Safety Code StandardWaterflow alarm and related sprinkler testing
NFPA 101 Life Safety Code StandardFire drills
NFPA 101 Life Safety Code StandardSprinkler head protection/testing
NFPA 101 Life Safety Code Standard; NFPA 70 National Electrical CodeElectrical wiring and adapters
18 Jun 2013Life Safety
18 Jun 2013Life Safety
Identified multiple deficiencies related to fire safety, electrical safety, and drill practices including unsealed sprinkler components, an unaddressed power tap, and lack of quarterly fire drills.
NFPA 101 Life Safety Code; NFPA 70; NFPA 13; NFPA 25; NFPA 72Sprinkler system and related components
NFPA 70; NFPA 101Electrical wiring and equipment safety
NFPA 101 Life Safety Code; NFPA 70Fire drills conducted quarterly
18 Jun 2013Life Safety
18 Jun 2013Life Safety
Found life-safety deficiencies including smoke barrier failures, improper fire-drill practices, and unsafe electrical/wiring conditions during the licensing review.
—Corridor doors and smoke barriers not meeting Life Safety Code requirements
—Fire drills conducted at unpredictable times
—Electrical wiring and equipment—temporary adapters usage
09 Jan 2013Complaint
09 Jan 2013Complaint
Investigated a complaint; found no deficiencies.
03 Jul 2012Complaint
03 Jul 2012Complaint
Investigated a July 3, 2012 complaint; found no deficiencies.
29 Jun 2012Revisit
29 Jun 2012Revisit
Verified corrections were completed for deficiencies related to ID Prefix under the Life Safety Code; corrections were completed on 2012-06-12.
Life Safety Code (NFPA 101)ID Prefix
Life Safety Code (NFPA 101)ID Prefix
Life Safety Code (NFPA 101)ID Prefix
28 Jun 2012Revisit
28 Jun 2012Revisit
Investigated the follow-up visit to verify corrections after the initial CMS findings were identified in the prior survey.
25 Apr 2012Complaint
25 Apr 2012Complaint
Identified multiple deficiencies affecting residents' rights information, advance directives and care planning, hydration and nutrition, infection control, and facility maintenance.
—Residents properly informed about rights, services, and charges
—Advance directives and Do Not Resuscitate (DNR) orders
—Care planning and updating (nutrition/weight concerns)
—Housekeeping and maintenance; sanitation
—Facility maintenance and safety (door frames etc.)
—Dietary/nutrition and hydration
—Continued care planning for dietary needs
—Nutrition and meal planning standards
—Infection control program
25 Apr 2012Life Safety
25 Apr 2012Life Safety
Identified multiple NFPA 101 Life Safety Code deficiencies, including issues with egress doors, boiler room/exits, and emergency power testing.
Verified prior deficiencies were corrected and the follow-up visit completed.
21 Oct 2011Complaint
21 Oct 2011Complaint
The facility had deficiencies related to falls and insufficient nursing assessment to detect early signs of brain injury after a fall.
Type A—Inadequate nursing assessment and monitoring following a fall
Type A—Falls management program deficiencies
07 Sept 2011Complaint
07 Sept 2011Complaint
Investigated the complaint and found no deficiencies.
06 Sept 2011Revisit
06 Sept 2011Revisit
Identified deficiencies during the post-certification revisit; several regulatory items were cited for non-compliance.
483.25Right to be free from abuse, neglect, and exploitation
483.75(10)(1)Resident rights; notification and transfer/discharge protections
12 Jul 2011Complaint
12 Jul 2011Complaint
The investigation found deficiencies in pain management documentation and in maintaining complete and accurate resident records.
—Inadequate pain management; lack of reassessment
—Records - Complete/Accurate/Accessible
08 Jun 2011Revisit
08 Jun 2011Revisit
Investigated the facility for compliance and identified deficiencies; all observed issues were addressed with corrections completed during the follow-up.
16 May 2011Revisit
16 May 2011Revisit
Investigated the reported deficiencies and found that required corrections were completed.
01 Apr 2011Life Safety
01 Apr 2011Life Safety
Investigated and identified life-safety deficiencies, including issues with exit access and the fire alarm system, coded as several violations.
Type ANFPA 101 Life Safety Code, Section 7.1.2.1; 19.2.1Exit access
Type ANFPA 70; NFPA 72; NFPA 101 Life Safety CodeFire alarm system maintenance and testing
Type ANFPA 101 Life Safety Code; Fire-resistive constructionFire-resistive construction
29 Mar 2011Complaint
29 Mar 2011Complaint
Identified deficiencies in resident care and safety, including inadequate continence care, insufficient engagement/activities, and problems with feeding assistance and documentation.
—Incontinence care and call light response
—Engagement/activities and staff interaction
—Feeding and mealtime assistance
29 Mar 2011Complaint
29 Mar 2011Complaint
Investigations identified several deficiencies in resident care, daily activities, and safety practices during the survey period, showing failure to consistently provide adequate care and meaningful activities.
—Care/Services Provided meet professional standards
—Activities/Program for residents
—Activity program/Resident engagement
—Resident care/Daily living
—Nursing services/supervision
—Nutritional/meals and hydration
—Resident mobility/assistive devices
—Safety/Environmental hazards
29 Mar 2011Licensure
29 Mar 2011Licensure
Concluded the facility was in compliance with state requirements.
28 Mar 2011Life Safety
28 Mar 2011Life Safety
During a licensing review, the agency identified several life-safety deficiencies, including blocked doors, damaged electrical wiring, inadequate sprinkler containment, and issues with smoking regulations.
NFPA 101 LIFE SAFETY CODE STANDARDDoor closings obstructed; corridor obstructions
NFPA 101 LIFE SAFETY CODE STANDARDHazard separation deficient in smoke compartments
NFPA 101 LIFE SAFETY CODE STANDARDSprinkler head placement/height not compliant
NFPA 101 LIFE SAFETY CODE STANDARDElectrical system/maintenance deficiencies noted
NFPA 101 LIFE SAFETY CODE STANDARDSmoking regulations not in required compliance
24 Mar 2011Life Safety
24 Mar 2011Life Safety
An investigation identified several life-safety deficiencies, including sprinkler system maintenance and operation issues, smoke barrier/exit concerns, and related door hardware noncompliances.
NFPA 101 Life Safety Code; NFPA 13Sprinkler head clearance/placement
NFPA 101 Life Safety Code; NFPA 13; NFPA 25Maintenance/testing of automatic sprinkler system
NFPA 70; Life Safety CodeDoor closers/operating hardware
7.1; 19.2.2.6; NFPA Life Safety CodeExit access/egress doors
NFPA 101 Life Safety CodeCeiling vent/equipment obstructing
NFPA Life Safety CodeQuarterly sprinkler inspections
18 Jan 2011Revisit
18 Jan 2011Revisit
Identified deficiencies in resident rights and care practices with several regulatory requirements cited.
483.13(c)Freedom from abuse, neglect, and exploitation
483.20(k)(3)(ii)Right to participate in planning of care
483.25(a)(3)Quality of life; nutrition and meals
483.25(d)Quality of life
483.25(i)Quality of life
483.30(a)Physician services
483.35(f)Medical/therapeutic services
03 Nov 2010Complaint
03 Nov 2010Complaint
Identified deficiencies in care, including injuries of unknown origin and inadequate support for meals and activities during the review period.
Type A—Continued From page 2
25 May 2010Revisit
25 May 2010Revisit
Verified corrections were completed after a follow-up visit; prior deficiencies were addressed.
42 CFR 483.65
12 May 2010Revisit
12 May 2010Revisit
Verified corrections completed for life safety code deficiencies following a follow-up review.
NFPA 101 Life Safety CodeLife Safety Code deficiency
NFPA 101 Life Safety CodeLife Safety Code deficiency
NFPA 101 Life Safety CodeLife Safety Code deficiency
NFPA 101 Life Safety CodeLife Safety Code deficiency
NFPA 101 Life Safety CodeLife Safety Code deficiency
NFPA 101 Life Safety CodeLife Safety Code deficiency
NFPA 101 Life Safety CodeLife Safety Code deficiency
NFPA 101 Life Safety CodeLife Safety Code deficiency
11 May 2010Revisit
11 May 2010Revisit
Investigated a revisit; found Life Safety Code deficiencies with corrections completed.
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
25 Mar 2010Licensure
25 Mar 2010Licensure
Identified deficiencies in privacy/confidentiality of resident records, protection from mistreatment and abuse, and the provision of an ongoing activities program.
—Dignity/Confidentiality of Resident Records
—Policies Prohibiting Mistreatment, Neglect, and Abuse
—Ongoing Activities Program
25 Mar 2010Licensure
25 Mar 2010Licensure
Found deficiencies in licensing regulations for nursing homes based on a survey conducted in late March 2010.
—Licensing regulations for nursing homes
26 Jun 2009Revisit
26 Jun 2009Revisit
Identified deficiencies during follow-up after a prior survey and noted that some uncorrected items were summarized for corrective action.
483.15(a)Resident rights
483.15(h)(2)Resident rights
483.20(b)Administration
483.20(k)(3)(i)Administration
483.25(d)Quality of life
483.25(h)Quality of life
483.65(a)Physical environment/safety
17 Jun 2009Revisit
17 Jun 2009Revisit
Verified corrective actions for prior deficiencies and found life-safety code issues corrected after follow-up.
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
23 Apr 2009Licensure
23 Apr 2009Licensure
Identified multiple deficiencies in resident dignity, nursing care, medication management, housekeeping, and infection control. These issues indicated violations of several regulatory requirements.
Type A483.15(a)DIGNITY
Type A483.20(k)(3)(i)COMPREHENSIVE ASSESSMENTS
Type A483.15(h)(2)HOUSEKEEPING/MAINTENANCE
Type A483.25(k)(3)NURSING SERVICES/MEDICATION ADMINISTRATION
Type A483.60(a) (and related subsections)PHARMACY SERVICES
Type A483.65INFECTIOUS DISEASE/INFECTION CONTROL
23 Apr 2009Licensure
23 Apr 2009Licensure
Investigated a tuberculosis testing requirement violation; found tuberculin testing was not completed before resident contact for an employee.
Type BWyoming Department of Health Rules and Regulations for Program Administration of Nursing Care Facilities, Chapter 11, Section 5, (b)(iv)(A)Tuberculin testing for employees
22 Apr 2009Life Safety
22 Apr 2009Life Safety
Multiple life-safety deficiencies were identified, including inadequate inspection of corridor doors, questions about smoke barriers and fire-resistance, and improper fire-drill timing and signage requirements.
NFPA 101 Life Safety Code Standard 19.3.2.1Corridor doors inspection
NFPA 101 Life Safety Code Standards 19.3.7.3, 19.7.5, 19.1.6.3, 19.1.6.4Smoke barriers and fire-resistance
NFPA 101 Life Safety Code Standard 19.7.1.2Fire drills timing
NFPA 101 Life Safety Code Standard (fire drill requirements)Fire drill scheduling
NFPA 101 Life Safety Code StandardFire-safety system standard
NFPA 101 Life Safety Code StandardSprinkler system not adequately documented
NFPA 99, NFPA 70 (as applicable to signage and electrical safety)Non-smoking signage in oxygen areas
NFPA 70Electrical wiring and equipment per NEC
20 Sept 2006Revisit
20 Sept 2006Revisit
Investigated deficiencies identified at follow-up and confirmed corrections completed.
483.10(b)(11)
483.20(k)(3)(i)
483.20(d)
483.25
29 Jun 2006Complaint
29 Jun 2006Complaint
Investigated deficiencies related to failure to notify changes in condition, incomplete care planning, inadequate resident assessments, and insufficient quality of care.
483.10(n)Unspecified CMS requirement related to resident rights/activities
483.20; 483.20(b)CMS facility requirements; resident care/rights under 483.20(b)
483.20(k)(3)(ii)Quality of care/behavioral oversight under 483.20(k)(3)(ii)
483.20(k)(3)(ii)Quality of care/oversight under 483.20(k)(3)(ii)
483.25(h)(1)Administration/medication oversight under 483.25(h)(1)
28 Apr 2006Revisit
28 Apr 2006Revisit
Identified multiple deficiencies in medication management, transfer/notice procedures, and resident care planning during an inspection. Observed unsafe medication administration and several gaps in assessments and written plans of care.
483.10(n)Self administration of drugs
483.15 or 483.20 (bed-hold/readmission related provision)Bed hold policy & readmission
483.20(k)(3)(ii)Comprehensive assessments
483.20(k)(3)(ii)Comprehensive care plans
483.25(h)(1)Accidents
14 Apr 2006Revisit
14 Apr 2006Revisit
Investigated a prior deficiency related to resident rights; corrective actions were completed and follow-up confirmed substantial compliance.
483.10(c)(2)-(5)Resident rights
31 Mar 2006Complaint
31 Mar 2006Complaint
Investigated a complaint; found no deficiencies identified.
17 Mar 2006Complaint
17 Mar 2006Complaint
Investigated found that resident funds were not properly safeguarded and written authorization to manage them was not obtained, with funds not kept separate from other funds.
483.10(c)(2)-(5)Protection of resident funds
03 Feb 2006Revisit
03 Feb 2006Revisit
Completed follow-up review found life-safety items corrected after prior deficiencies.
12 Jan 2006Licensure
12 Jan 2006Licensure
Identified a deficiency related to the use of physical restraints and resident safety.
483.13(a)PHYSICAL RESTRAINTS
13 Dec 2005Life Safety
13 Dec 2005Life Safety
The inspection identified multiple life-safety deficiencies including gaps in fire/smoke barrier doors, improper interior finishes, and issues with electrical safety and emergency equipment.
Type ANFPA 101 Life Safety Code StandardDoors and exit enclosures
Type ANFPA 101 Life Safety Code StandardSmoke barrier doors
Type ANFPA 101 Life Safety Code StandardSmoke barrier doors/storage room access
Type ANFPA 101 Life Safety Code StandardInterior decorations and structural finishes
Type ANFPA 70 National Electrical CodeElectrical wiring and equipment safety
17 Nov 2005Complaint
17 Nov 2005Complaint
Investigated a complaint and found no deficiencies.
27 Jul 2005Revisit
27 Jul 2005Revisit
Investigated a prior deficiency; follow-up visit completed.
07 Jul 2005Complaint
07 Jul 2005Complaint
Investigated the complaint and found no deficiencies identified.
15 Jun 2005Complaint
15 Jun 2005Complaint
Investigated transfer and discharge practices and found that a resident was not notified of discharge nor given the required discharge notices and information.
483.12(a)(4)-(6)Transfer and discharge requirements
Disclaimer
Mirador Living is not affiliated with the owner or operator(s) of Shepherd of the Valley Rehabilitation and Wellness. The information above has not been verified or approved by the owner or operator. For exact information, please contact Shepherd of the Valley Rehabilitation and Wellness directly. There is no cost for this service. We are compensated by the community you select.
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Shepherd of the Valley Rehabilitation and Wellness