Shepherd of the Valley Rehabilitation and Wellness

    60 Magnolia, Casper, WY 82604
    • Assisted Living
    • Memory Care
    • Skilled Nursing

    Kind, caring staff; mother thriving

    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

    Schedule a Tour

    Date of Tour
    Time Window
    Tour Type

    You selected in-person tour on in the

    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

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

    Reviews written on Mirador

    We have no reviews to show about Shepherd of the Valley Rehabilitation and Wellness.

    Help other families by writing a review about your experience with this community.

    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

    Map showing location of Shepherd of the Valley Rehabilitation and Wellness

    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 numbernh-186
    Facility typeNursing Home

    Inspection Reports

    220

    Reports

    48

    Type A Citations

    2

    Type B Citations

    135

    Complaints

    21

    Years

    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
    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
    Verified compliance with all regulations. All previously cited deficiencies were corrected and no new noncompliance was found.
    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
    Verified compliance after a revisit; all prior deficiencies were corrected and no new noncompliance was found.
    17 Dec 2024Revisit
    Verified that prior deficiencies were corrected and current safety requirements are met.
    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
    Found no deficiencies. Confirmed compliance with state requirements.
    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 101, 19.7.6; 8.3.3.1; NFPA 80, 5.2, 5.2.3Maintenance, Inspection & Testing - Doors
    • 2012 NFPA 99, Ch.10, 4.4.1.2Electrical Systems - Essential Electric System
    22 Oct 2024Revisit
    Concluded that all prior deficiencies were corrected and no new noncompliance was found.
    07 Oct 2024Revisit
    Verified compliance after a follow-up visit; all previously cited deficiencies were corrected and no new noncompliance found.
    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
    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
    Verified that prior deficiencies were corrected and no new noncompliance was found.
    12 Jun 2024Revisit
    Found no deficiencies; all previously noted deficiencies were corrected.
    25 Apr 2024Complaint
    Investigated a complaint and found no deficiencies.
    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
    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
    Found no deficiencies.
    14 Dec 2023Revisit
    Confirmed no deficiencies cited; prior findings were resolved.
    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
    Verified compliance following a Life Safety Code revisit; all prior deficiencies were corrected and no new noncompliance was found.
    06 Oct 2023Revisit
    Concluded that all deficiencies were corrected and compliance was achieved.
    03 Oct 2023Revisit
    Verified that all previously cited deficiencies were corrected and no new noncompliance was found.
    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.
    • 483.10(c)(7)Resident Self-Admin Meds-Clinically Approp
    • 483.21(b)(1)-(3)Develop/Implement Comprehensive Care Plan
    • 483.25Quality of Care
    • 483.25(c)(1)-(3)Increase/Prevent Decrease in ROM/Mobility
    • 483.25(d)(1)-(2)Free of Accident Hazards/Supervision/Devices
    • 483.25(i)Respiratory/Tracheostomy Care and Suctioning
    • 483.60(c)(1)-(7)Menus Meet Resident Nds/Prep in Adv/Followed
    • 483.60(i)(1)-(2)Food Procurement,Store/Prepare/Serve-Sanitary
    • 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
    Found no deficiencies after a licensure survey conducted August 7-10, 2023.
    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 101 (2012) 19.2.2.2.4(2); 7.2.1.6.1.1(4)Egress Doors
    • NFPA 101 (2012) 19.2.2.2.1; 7.2.1.8Doors with Self-Closing Devices
    • NFPA 101 (2012) 19.2.10.1; 7.10.1.1; 7.10.1.5.1Exit Signage
    • 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
    Found a bathroom hand sink water temperature exceeding regulatory limits (over 119°F) in room 133; corrective actions were initiated and ongoing audits planned.
    • WDH Chapter 11 Section 6(a)(iv)Water temperatures – handwashing sinks
    18 Jul 2023Revisit
    Verified all previously cited deficiencies were corrected and no new noncompliance was found.
    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
    Investigated complaint allegations and found no deficiencies. No violations were identified.
    16 Mar 2023Complaint
    Investigated the complaint; found no deficiencies identified.
    08 Feb 2023Complaint
    Found no deficiencies.
    31 Jan 2023Complaint
    Investigated the complaint and found no deficiencies identified related to the complaint.
    23 Dec 2022Revisit
    Confirmed compliance with federal requirements after a follow-up survey; no deficiencies were identified.
    02 Nov 2022Revisit
    Found no deficiencies; previous issues were corrected and compliance was confirmed.
    02 Nov 2022Revisit
    Verified that all deficiencies were corrected and compliance with requirements was restored.
    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
    Verified prior deficiencies were corrected and found no new noncompliance.
    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 8.3.3.1; CMS S&C 17-38-LSC; NFPA 80Maintenance, Inspection & Testing - Doors
    • 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
    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
    Investigated deficiencies found in resident assessments, care planning, restorative services, medication management, staff qualifications, and infection control.
    • 42 CFR 483.20(b)(1)(2)(i)(iii); 42 CFR 483.20(b)(2)Comprehensive Assessments & Timing
    • 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
    Verified no deficiencies found and prior deficiencies corrected. Concluded compliance with all regulations surveyed.
    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
    Found no deficiencies after a follow-up visit; all prior deficiencies were corrected and no new noncompliance was found.
    22 Mar 2022Revisit
    Verified all prior deficiencies were corrected and no new noncompliance was found.
    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
    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
    Verified prior deficiencies were corrected and confirmed ongoing compliance.
    17 Sept 2021Revisit
    Verified prior deficiencies were corrected and found no new noncompliance.
    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, Section 7.2.1.8.2; 18.2.2.2.7; 18.2.2.2.8; 19.2.2.2.7; 19.2.2.2.8Doors with Self-Closing Devices
    • 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
    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
    Found no deficiencies. The survey determined compliance with state requirements.
    08 Jul 2021Complaint
    Found no deficiencies identified during the complaint investigation and the COVID-19 focused infection control survey.
    30 Mar 2021Complaint
    Found no deficiencies identified during the complaint and COVID-19 focused infection control reviews.
    12 Mar 2021Revisit
    Verified compliance with all regulations surveyed.
    24 Feb 2021Revisit
    Verified deficiencies corrected and compliance restored.
    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
    Found no deficiencies. The survey concluded compliance with state requirements.
    27 Jan 2021Life Safety
    Found deficiencies in keeping fire doors properly closed and in securing oxygen cylinders.
    • 2012 NFPA 101, Section: 7.2.1.15.2; 2010 NFPA 80, Section: 5.2.4.2(6)Doors with Self-Closing Devices
    • 2012 NFPA 99, Section: 11.6.2.3Gas Equipment - Precautions for Handling Oxygen Cylinders and Manifolds
    06 Jan 2021Revisit
    Found all previously cited deficiencies corrected and no new noncompliance identified.
    06 Jan 2021Revisit
    Found no deficiencies; prior deficiencies were corrected and no new noncompliance was found.
    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
    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
    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
    Found no deficiencies; prior issues were addressed and compliance was confirmed.
    01 May 2020Licensure
    Found no deficiencies.
    31 Mar 2020Licensure
    Concluded that no deficiencies were identified in the COVID-19 focused infection control assessment.
    13 Mar 2020Life Safety
    Verified prior life safety code deficiencies were corrected and compliance was reestablished.
    31 Jan 2020Complaint
    Identified multiple deficiencies across assessment accuracy, dementia care, medication management, activities, nutrition, and infection control.
    • 42 CFR 483.10(g)(17)-(18)Medicaid/Medicare Coverage/Liability Notice
    • 42 CFR 483.12(b)Abuse/Neglect Policies
    • 42 CFR 483.20(b)Comprehensive Assessments & Timing
    • 42 CFR 483.20(g)Accuracy of Assessments
    • 42 CFR 483.24(c)Activities Meet Interest/Needs
    • 42 CFR 483.40(b)(3)Treatment/Service for Dementia
    • 42 CFR 483.45(a)-(c)Pharmacy Services
    • 42 CFR 483.45(e)Free from Unnecessary Psychotropic Drugs/PRN Use
    • 42 CFR 483.45(g)-(h)Labeling/Storage of Drugs and Biologicals
    • 42 CFR 483.60(i)Food Procurement, Store/Prepare/Serve-Sanitary
    • 42 CFR 483.80Infection Control
    31 Jan 2020Licensure
    Determined that the facility was in compliance with state requirements.
    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, 19.2.2.2.4; 7.2.1.6.1.1(4)Egress Doors
    • NFPA 101 2012, 19.3.5.1; 9.7.1.1; NFPA 13 2010, 6.2.7Sprinkler System - Installation
    • 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
    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
    Determined all requirements were met during the survey.
    21 Jan 2020Revisit
    Follow-up visit found all previously cited deficiencies corrected and no new noncompliance identified.
    21 Jan 2020Revisit
    Verified that prior deficiencies were corrected and no new noncompliance was found.
    21 Jan 2020Revisit
    Verified that previously cited deficiencies were corrected and found no new noncompliance. All regulations surveyed were in compliance.
    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
    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
    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
    Verified that all previous deficiencies were corrected and no new noncompliance was found.
    16 Oct 2019Complaint
    Found no deficiencies. The complaint investigation concluded with no deficiencies identified.
    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
    Determined no deficiencies identified in the complaint investigation.
    29 May 2019Complaint
    Investigated a complaint and found no deficiencies identified.
    24 Apr 2019Revisit
    Confirmed that prior deficiencies were corrected and no new noncompliance was identified during the follow-up.
    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
    Verified compliance with all surveyed regulations. No deficiencies were found.
    11 Apr 2019Complaint
    Investigated a complaint survey conducted from 04/03/2019 to 04/11/2019 and found no deficiencies.
    25 Mar 2019Revisit
    Verified that all prior deficiencies were corrected and compliance was restored.
    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
    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
    Verified all prior deficiencies were corrected on follow-up visit.
    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
    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
    • 2012 NFPA 101, Sections: 19.xx; 7.xx; 4.6.xxEmergency lighting/testing deficiency
    • 2012 NFPA 101, 19.3.2.1; 19.3.3.1; 19.3.3.2Partitions/doors not meeting code requirements
    • 2012 NFPA 101, Sections: 19.7.4; NFPA 25Sprinkler/standpipe maintenance and testing
    • 2012 NFPA 101; CFR(s): NFPA 101Smoking regulations
    • 2012 NFPA 101, Sections: 9.7.4; 11.6.2.3; NFPA 99Gas equipment storage and cylinder handling
    14 Feb 2019Licensure
    Found no deficiencies identified during the review. The findings indicated compliance with state requirements.
    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
    Verified previous deficiencies were corrected and no new noncompliance was found.
    03 Jan 2019Revisit
    Verified that prior deficiencies were corrected and no new noncompliance was found.
    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
    Found no deficiencies.
    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
    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
    Confirmed compliance after revisit; all prior deficiencies were corrected.
    27 Sept 2018Revisit
    Found no deficiencies. All prior deficiencies were corrected, and no new noncompliance was found.
    27 Sept 2018Revisit
    Found no deficiencies. A revisit confirmed that prior deficiencies were corrected.
    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
    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
    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
    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
    Concluded that all previously cited deficiencies were corrected and no new noncompliance was found.
    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
    Investigated the complaint; found no deficiencies.
    08 Mar 2018Complaint
    Investigated a complaint and found no deficiencies.
    02 Feb 2018Revisit
    Verified all prior deficiencies were corrected and found no new noncompliance.
    02 Feb 2018Revisit
    Concluded that all previously cited deficiencies were corrected and no new noncompliance was found.
    01 Feb 2018Revisit
    Verified all prior deficiencies were corrected and no new noncompliance found.
    01 Feb 2018Revisit
    Verified that prior deficiencies were corrected; no new noncompliance found and all regulations surveyed were met.
    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
    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.
    • Ch 11 Sec 6 (a)(iv) Physical EnvironmentPhysical Environment
    14 Nov 2017Life Safety
    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
    • 2012 NFPA 101 Life Safety CodeCorridor - Doors
    • 2012 NFPA 101; NFPA 99; NFPA 101 (smoking provisions); NFPA 55Smoking Regulations
    • 2012 NFPA 101; NFPA 99; NFPA 55 (gas/liquid oxygen); NFPA 11 (oxygen storage) 2009/2010 editions referencedGas Equipment - Liquid Oxygen Equipment
    14 Nov 2017Life Safety
    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
    Concluded that compliance was restored after a follow-up visit addressing a prior complaint investigation.
    24 May 2017Complaint
    Investigated a complaint; found no deficiencies.
    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
    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
    Investigated a prior complaint and concluded the facility was back in compliance after a follow-up visit.
    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
    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
    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
    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
    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
    Investigated a complaint and found deficiencies related to housekeeping/maintenance and resident care procedures, with corrective actions planned.
    • Type AHousekeeping & Maintenance Services
    20 Oct 2016Licensure
    Found in compliance with state requirements; no deficiencies cited.
    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
    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
    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
    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
    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
    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
    Verified that previously cited deficiencies were corrected.
    22 Jan 2016Complaint
    Investigated the complaint and found no deficiencies.
    03 Dec 2015Revisit
    Investigated the allegation and found no deficiencies. No violations were cited.
    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
    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
    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
    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
    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
    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
    Investigated deficiencies related to resident supervision and safety, with noted staffing and care-practice concerns observed during the visit.
    15 Jul 2015Complaint
    Investigated a complaint survey and found no deficiencies identified.
    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
    Investigated the complaint; found no deficiencies.
    09 Apr 2015Revisit
    Investigated deficiencies cited during a revisit; corrections have been completed.
    • 483.20(k)(3Xi)
    • 483.25(c)
    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
    Found no deficiencies cited. Corrections were completed for all previously identified items.
    07 Nov 2014Revisit
    Found no deficiencies. The revisit confirmed prior corrective actions were completed.
    16 Oct 2014Revisit
    Investigated the follow-up to address previously reported deficiencies; corrections completed for all items observed.
    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
    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
    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
    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
    Determined the provider was in substantial compliance with state requirements.
    18 Mar 2014Revisit
    Cited deficiencies under resident rights; corrections completed.
    • 483.60(b), (d), (e)Resident rights
    18 Mar 2014Revisit
    Investigated uncorrected deficiencies from a prior survey during a follow-up visit.
    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
    Found no deficiencies.
    07 Nov 2013Revisit
    Found no deficiencies.
    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
    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
    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
    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
    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
    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
    Investigated a complaint; found no deficiencies.
    03 Jul 2012Complaint
    Investigated a July 3, 2012 complaint; found no deficiencies.
    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
    Investigated the follow-up visit to verify corrections after the initial CMS findings were identified in the prior survey.
    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
    Identified multiple NFPA 101 Life Safety Code deficiencies, including issues with egress doors, boiler room/exits, and emergency power testing.
    • NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code – Egress/door integrity
    • NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code – Construction and fire protection
    • NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code – Exit doors/egress
    • NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code – Emergency power / generators
    • NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code – Continued deficiencies
    • NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code – Generator testing
    • NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code – Generator testing
    18 Jan 2012Complaint
    Found no deficiencies.
    22 Nov 2011Revisit
    Verified prior deficiencies were corrected and the follow-up visit completed.
    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 AInadequate nursing assessment and monitoring following a fall
    • Type AFalls management program deficiencies
    07 Sept 2011Complaint
    Investigated the complaint and found no deficiencies.
    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
    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
    Investigated the facility for compliance and identified deficiencies; all observed issues were addressed with corrections completed during the follow-up.
    16 May 2011Revisit
    Investigated the reported deficiencies and found that required corrections were completed.
    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
    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
    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
    Concluded the facility was in compliance with state requirements.
    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
    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
    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
    Identified deficiencies in care, including injuries of unknown origin and inadequate support for meals and activities during the review period.
    • Type AContinued From page 2
    25 May 2010Revisit
    Verified corrections were completed after a follow-up visit; prior deficiencies were addressed.
    • 42 CFR 483.65
    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
    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
    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
    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
    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
    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
    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
    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
    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
    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
    Investigated deficiencies related to failure to notify changes in condition, incomplete care planning, inadequate resident assessments, and insufficient quality of care.
    • 483.10(b)(11)NOTIFICATION OF CHANGES
    • 483.20(k)(3)(v)COMPREHENSIVE CARE PLANS
    • 483.20(d)RESIDENT ASSESSMENT - USE
    • 483.75QUALITY OF CARE
    19 May 2006Revisit
    Identified deficiencies requiring corrective actions; corrections completed.
    • 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
    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
    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
    Investigated a complaint; found no deficiencies identified.
    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
    Completed follow-up review found life-safety items corrected after prior deficiencies.
    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
    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
    Investigated a complaint and found no deficiencies.
    27 Jul 2005Revisit
    Investigated a prior deficiency; follow-up visit completed.
    07 Jul 2005Complaint
    Investigated the complaint and found no deficiencies identified.
    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.

    Are you an owner or operator of this community?

    Claim this listing to receive messages from prospective customers and manage your community page.

    Nearby Communities

    Assisted Living in Nearby Cities

    1. 28 facilities$6,289/mo
    2. 12 facilities$6,240/mo
    3. 19 facilities$6,075/mo
    4. 28 facilities$6,289/mo
    5. 10 facilities$6,203/mo
    6. 12 facilities$5,824/mo
    7. 21 facilities$6,257/mo
    8. 19 facilities$6,257/mo
    9. 5 facilities$5,727/mo
    10. 3 facilities$3,935/mo
    11. 6 facilities$4,394/mo
    12. 6 facilities$4,394/mo
    © 2026 Mirador Living