My mom has received compassionate, consistent care here - nurses, CNAs and the rehab team truly know residents and treat them like family. Administration and the DON are accessible and proactive, staff keep us informed (and even helped with Medicaid paperwork). The facility is clean, friendly, and the whole team - dietary, housekeeping, maintenance - makes visits comfortable. I'm grateful for the attentive, professional staff and happily recommend this place for long-term care.
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
3.49·(43)
Overall rating
5
4
3
2
1
Care
3.1
Staff
3.1
Meals
2.0
Amenities
3.5
Value
1.0
Pros
Professional and knowledgeable nursing team
Visible Director of Nursing and administrative presence
Responsive administration and management
Consistent, compassionate direct-care staff
Attentive CNAs and nursing assistants
Effective interdisciplinary support (dietary, housekeeping, maintenance)
Clean, odor-controlled common areas
Proactive family communication and care coordination
Rehabilitation and therapy services
Assistance with insurance/Medicaid paperwork
Resident-centered, home-like atmosphere
High staff loyalty and continuity on many units
Cons
Inconsistent quality of direct care across shifts and units
Unreliable responsiveness to resident requests and call lights
Medication-administration and documentation gaps
Inconsistent bathing and personal-care schedules
Variable cleanliness and odor concerns in some units
Inconsistent meal service timing and food temperature
Staffing instability and short-staffed shifts
Staff conduct and communication tone
Allegations of theft and dishonest billing practices
Inadequate follow-through on personnel investigations/background checks
Summary of reviews
The reviews present a mixed but actionable picture of Granite Rehabilitation and Wellness. Many families and residents describe strong clinical leadership and a professional nursing presence; the Director of Nursing and administration are often noted as accessible and responsive. When the care team is functioning well, reviewers highlight compassionate CNAs and nurses, good interdisciplinary support from dietary, housekeeping and maintenance, proactive family communication, and effective rehabilitation services. These strengths contribute to a stable, resident-centered atmosphere for long-term care and post-acute rehabilitation for a substantial portion of families.
However, there are recurring operational themes that temper those positives. Several reviews point to inconsistent quality of direct care that appears to vary by unit and shift: delayed responses to calls, gaps in medication administration or documentation, and uneven adherence to bathing and personal-care schedules. Relatedly, staffing instability and short-staffed shifts are described as a driver of delayed assistance and missed tasks. These patterns manifest as tangible service shortfalls for some residents and create variability in daily care experiences.
Dining and environmental feedback is similarly mixed. The facility receives praise for generally clean, comfortable common areas and coordinated support services, but complaints include inconsistent meal timing and food temperature and localized sanitation or odor concerns on certain units. Housekeeping and dietary staff are also cited as contributors to a smooth experience in other reports, which suggests that cleanliness and meal-service performance may be uneven across areas or shifts rather than universally deficient.
Communication and management practice is another bifurcated area. Many families commend the administration for responsiveness, clear communication, and assistance with paperwork and care coordination. Conversely, other accounts describe poor communication tone, rudeness from some staff members, and frustration with how investigations or personnel concerns are handled. There are also serious allegations relating to personal-item security and billing transparency; these claims indicate potential gaps in property management and administrative oversight that warrant careful review.
For prospective residents and families, the reviews suggest that outcomes at Granite Rehabilitation and Wellness can depend heavily on the specific unit, shift, and individual staff on duty. When evaluating the facility, consider meeting the DON and administrator, asking for up-to-date staffing patterns and therapy schedules, touring the particular unit where a resident will live, and clarifying policies on personal belongings, billing, and incident investigations. The facility demonstrates clear strengths in clinical leadership and caregiving when operations are aligned, but the documented variability and the more serious administrative concerns are important factors to address during placement decisions and ongoing oversight.
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Medicare Ratings
2·/ 5
Overall
Health Inspection
Staffing
Quality Measures
Ratings from the U.S. Centers for Medicare & Medicaid Services (Care Compare). View on Medicare.gov
Location
Granite Rehabilitation and Wellness is located at 3128 Boxelder Dr, Cheyenne, WY, 82001.
About Granite Rehabilitation and Wellness
Granite Rehabilitation and Wellness is dedicated to providing comprehensive care in a peaceful and comforting environment, supporting individuals through both short-term rehabilitation and long-term skilled nursing care. The community places a strong emphasis on patient-centered service, ensuring that each resident’s unique needs and preferences shape their daily experience. From personalized meal choices to a variety of engaging activities, Granite Rehabilitation and Wellness strives to create an atmosphere that feels warm, welcoming, and as home-like as possible while delivering the necessary medical support.
The specialized rehabilitation programs at Granite Rehabilitation and Wellness are tailored for residents recovering from illness, injury, or surgery. Their therapy services are designed to restore mobility, strength, independence, and overall well-being. Physical therapy focuses on improving strength, balance, and mobility while alleviating pain and reducing the risk of falls, helping residents regain their physical health. Occupational therapy helps individuals reclaim essential daily living skills such as dressing, grooming, and meal preparation through adaptive tools and techniques. Speech and language therapy supports the improvement of communication, cognitive function, and swallowing ability, aiding residents in regaining confidence and enhancing their quality of life.
For those facing Alzheimer’s disease and other dementia-related conditions, Granite Rehabilitation and Wellness delivers compassionate memory support in a safe, structured, and nurturing environment. Care teams offer stability, specialized assistance, and personalized programs meant to enrich everyday life, foster independence, and provide reassurance. The approach emphasizes guidance for families as well, equipping them with resources, education, and expert care so that their loved ones can thrive in a secure and compassionate setting.
Granite Rehabilitation and Wellness also offers a Respite Stay program, providing short-term care solutions for families who need temporary support or recovery time after a hospital stay. The respite care program gives peace of mind, ensuring residents receive skilled nursing care around the clock in a supportive, welcoming atmosphere. This service is especially helpful for caregivers needing a break, individuals requiring post-hospital recovery, or those seeking trial stays before making a long-term decision.
In addition to core services, the community supplies a range of supplementary care options to support a variety of health needs. These include wound care, IV therapy, pain management, catheter care, enteral feeding programs, off-site dialysis, post-hospital extended care, and coordination for dental, vision, and audiology appointments. Granite Rehabilitation and Wellness is committed to prioritizing resident well-being at every stage of the care journey, offering guidance and connecting individuals with the right resources when needed.
The community is recognized for its commitment to excellence in quality care, reflected in its welcoming approach and dedication to enhancing healthcare and quality of life for residents and their families. With a team devoted to compassion, support, and personal growth, Granite Rehabilitation and Wellness offers rewarding career paths in senior living, inviting those who are passionate about making a positive difference to join their caring environment. Residents and families can stay connected and informed with online tools to manage payments, meet the team, and participate in community events, making Granite Rehabilitation and Wellness a truly engaging and supportive place to live and recover.
People often ask...
Granite Rehabilitation and Wellness offers assisted living, memory care, and skilled nursing.
There are 1 photos of Granite Rehabilitation and Wellness on Mirador.
The full address for this community is 3128 Boxelder Dr, Cheyenne, WY 82001.
No, Granite 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-191
Facility type
Nursing Home
Inspection Reports
202
Reports
35
Type A Citations
0
Type B Citations
112
Complaints
21
Years
20 Aug 2025Revisit
20 Aug 2025Revisit
Verified that previously cited deficiencies were corrected and no new noncompliance was found.
24 Jun 2025Complaint
24 Jun 2025Complaint
Identified deficiencies related to unsafe discharge planning and inadequate behavioral health care for a resident with dementia. The findings showed missing documentation and insufficient communication with receiving facilities.
483.45(e)(1)-(5)Free from Unnec Psychotropic Meds/PRN Use
483.45(g)(h)(1)-(2)Label/Store Drugs and Biologicals
483.80(a)-(f)Infection Prevention & Control
06 Aug 2024Life Safety
06 Aug 2024Life Safety
Found widespread life-safety code and fire protection deficiencies across the building, including damaged ceilings, egress door issues, and failures in alarm, sprinkler, extinguisher maintenance, electrical testing, and oxygen handling.
Type ANFPA 101 2012 Sec. 19.1.1.1.3 and 4.6.12.1General requirements
Type ANFPA 101 2012 Sec. 19.2.2.2.1 and 7.2.1.6.1.1Egress Doors
Type ANFPA 70 and NFPA 72 (as referenced); 2010 NFPA 72Fire Alarm System - Testing and Maintenance
Type ANFPA 101 2012 Sec. 19.3.5 and 9.7; NFPA 13 2010 Sec. 6.2.7.1Sprinkler System - Installation
Type ANFPA 25 5.3.2; 2012 NFPA 101 Sec. 19.3.5.1 and 9.7.5; 2011 NFPA 25 Sec. 5.3.2Sprinkler System - Maintenance and Testing
Type ANFPA 101 2012 Sec. 19.3.5.12 and 9.7.4.1; NFPA 10 18.3.5.12, 19.3.5.12Portable Fire Extinguishers
Type ANFPA 101 2012 Sec. 19.3.6.3.2(2)Corridor - Doors
Type ANFPA 99 Sec. 6.3.4; 6.3.2; 6.3.3.2Electrical Systems - Maintenance and Testing
Type ANFPA 99 Sec. 11.6.2.3(11)Gas Equipment - Precautions for Handling Oxygen
17 Jul 2024Complaint
17 Jul 2024Complaint
Investigated the complaint and found no deficiencies identified. No violations were cited.
16 May 2024Revisit
16 May 2024Revisit
Verified compliance after a follow-up visit; all prior deficiencies were corrected and no new noncompliance was found.
16 May 2024Complaint
16 May 2024Complaint
Investigated a complaint and found no deficiencies.
12 Apr 2024Complaint
12 Apr 2024Complaint
Identified several deficiencies across grievances handling, bathing/ADL care, dietary staffing, food quality, and infection control, indicating noncompliance with federal requirements.
Type ACFR 483.10(j)(1)-(4)Grievances
Type ACFR 483.24(a)(2)ADL Care
CFR 483.60(a)(3); 483.60(b)Sufficient Dietary Support Personnel
CFR 483.80(a)(1)-(4); 483.80(e); 483.80(f)Infection Prevention & Control
09 Nov 2023Revisit
09 Nov 2023Revisit
Verified that all previous deficiencies were corrected and no new noncompliance was found.
11 Oct 2023Complaint
11 Oct 2023Complaint
Investigated a complaint and found deficiencies in obtaining and implementing follow-up physician orders for wound care after hospitalization for two residents, with missing orders and lack of wound care documentation.
CFR 483.25Quality of Care
19 Jul 2023Revisit
19 Jul 2023Revisit
Verified prior life-safety deficiencies were corrected and compliance was achieved.
19 Jul 2023Revisit
19 Jul 2023Revisit
Verified compliance after a follow-up visit; all previously cited deficiencies were corrected.
07 Jul 2023Complaint
07 Jul 2023Complaint
Determined that no deficiencies were identified for the complaint intake survey. The COVID-19 focused infection control survey also found no deficiencies.
30 Jun 2023Revisit
30 Jun 2023Revisit
Concluded that all previous deficiencies were corrected and no new noncompliance was found.
08 Jun 2023Complaint
08 Jun 2023Complaint
Found no deficiencies identified in the complaint investigation.
25 May 2023Complaint
25 May 2023Complaint
Identified multiple deficiencies in continence care, psychotropic medication management, dietary service, dishwashing sanitation, and infection control.
§483.25(e)(1)-(3)Bowel/Bladder Incontinence, Catheter, UTI
§483.45(e)Free from Unnecessary Psychotropic Medications/PRN Use
NFPA 101, 2012, 19.3.5.1; NFPA 25, 2011, 5.1.1.2Sprinkler System - Maintenance and Testing
NFPA 101, 2012, 19.5.3; ASME A17.3-2008Elevators
NFPA 101, 2012, 19.7.8Portable Space Heaters
NFPA 110; NFPA 70; NFPA 99Electrical Systems - Essential Electric System
NFPA 99 10.2.3.6; NFPA 70 400.8; NFPA 70 590.3(D); NFPA 99 10.2.4Electrical Equipment - Power Cords and Extension Cords
23 May 2023Life Safety
23 May 2023Life Safety
Investigated hot water temperatures at hand sinks and found readings outside the required 95-110°F range. Also observed substantial storage in an elevator machine room.
2006 IPC 416.5; 2006 Guidelines for the Design and Construction of Health Care Facilities, Table 4.1-3IPC Life Safety - International Plumbing Code
2006 IFC, Section 315.2.3IFC Elevator machine room storage
27 Apr 2023Revisit
27 Apr 2023Revisit
Verified compliance after a follow-up visit; all deficiencies were corrected and no new noncompliance was found.
24 Apr 2023Complaint
24 Apr 2023Complaint
Found no deficiencies identified during the complaint investigation.
21 Mar 2023Complaint
21 Mar 2023Complaint
Investigated the complaint survey and found no deficiencies identified.
07 Mar 2023Complaint
07 Mar 2023Complaint
Found opioid pain medication was not available as ordered for a resident with chronic pain, leading to gaps in timely pain management.
CFR 483.25(k)Pain Management
16 Feb 2023Revisit
16 Feb 2023Revisit
Verified that all prior deficiencies were corrected and no new noncompliance was found.
23 Nov 2022Complaint
23 Nov 2022Complaint
Investigated a complaint about abuse and found a resident experienced unwanted sexual touching by another resident, indicating insufficient protection against abuse.
CFR 483.12(a)(1)Freedom from Abuse, Neglect, Exploitation
26 Oct 2022Complaint
26 Oct 2022Complaint
Investigated the complaint and found no deficiencies.
07 Sept 2022Complaint
07 Sept 2022Complaint
Found no deficiencies related to the complaint investigation.
14 Jul 2022Complaint
14 Jul 2022Complaint
Identified unsafe transfer practices that resulted in a resident sustaining a fracture. The finding showed staff did not follow care plans for transfers.
42 CFR 483.25(d)Free of Accident Hazards/Supervision/Devices
08 Jun 2022Revisit
08 Jun 2022Revisit
Found no deficiencies and confirmed compliance after the revisit.
06 Jun 2022Complaint
06 Jun 2022Complaint
Identified no deficiencies during the complaint investigation and COVID vaccination review.
27 May 2022Revisit
27 May 2022Revisit
Confirmed all previously cited deficiencies were corrected and no new noncompliance was found.
27 May 2022Revisit
27 May 2022Revisit
Verified no deficiencies and confirmed prior deficiencies were corrected during a follow-up visit.
14 Apr 2022Licensure
14 Apr 2022Licensure
An inspection identified deficiencies in bathing for dependent residents, catheter care, kitchen sanitation, and infection prevention and control. Several residents did not receive consistent bathing, catheter-related care was not properly implemented, kitchen sanitation was inadequate, and infection control practices were not consistently followed.
483.24(a)(2)ADL Care Provided for Dependent Residents
Identified failures to implement proper transmission-based precautions for COVID-19, including failures to replace N95 masks after leaving isolation rooms.
42 CFR 483.80Infection control
25 Jan 2022Complaint
25 Jan 2022Complaint
Determined that no deficiencies were identified during the complaint and infection control surveys.
14 Dec 2021Complaint
14 Dec 2021Complaint
Found no deficiencies after reviewing a complaint and a COVID-19 focused infection control survey.
27 Oct 2021Complaint
27 Oct 2021Complaint
Found no deficiencies. Investigated a complaint intake and a COVID-19 focused infection control survey.
18 Aug 2021Complaint
18 Aug 2021Complaint
Investigated complaints and a focused infection control survey found no deficiencies.
16 Aug 2021Revisit
16 Aug 2021Revisit
Verified no deficiencies were found during the revisit.
01 Jun 2021Revisit
01 Jun 2021Revisit
Found no deficiencies.
24 May 2021Complaint
24 May 2021Complaint
Found visitors were told rapid COVID-19 testing was mandatory for visitation, contrary to CMS guidance.
CFR 483.10(f)(4)(ii)-(v)Right to Receive/Deny Visitors
19 May 2021Revisit
19 May 2021Revisit
Found no deficiencies. Follow-up visit confirmed previous deficiencies corrected.
08 Apr 2021Licensure
08 Apr 2021Licensure
Identified multiple deficiencies across skin integrity, supervision for transfers, oxygen management, psychotropic medication use, and infection control.
CFR 483.25(b)(1)(i)(ii)Treatment/Svcs to Prevent/Heal Pressure Ulcer
CFR 483.25(d)(1)(2)Free of Accident Hazards/Supervision/Devices
CFR 483.25(i)Respiratory/Tracheostomy Care and Suctioning
CFR 483.45(c)(3)(e)(1)-(5)Free from Unnec Psychotropic Meds/PRN Use
CFR 483.80(a)(1)(2)(4)(e)(f)Infection Prevention & Control
08 Apr 2021Licensure
08 Apr 2021Licensure
Confirmed compliance with state requirements after a licensure survey.
06 Apr 2021Life Safety
06 Apr 2021Life Safety
Identified multiple life safety deficiencies related to egress doors, lighting, signage, hazardous areas, sprinklers, extinguishers, and electrical systems.
NFPA 101 Life Safety Code, 2012 Edition; NFPA 70, 2011 Edition; Sections 19.5.1.1; 9.1.1; 9.1.2Utilities - Gas and Electric
NFPA 101 Life Safety Code, 2012 Edition; NFPA 70, 2011 Edition; Section 9.1.2; 10.2.3.6Electrical Equipment - Power Cords and Extension Cords
08 Jan 2021Complaint
08 Jan 2021Complaint
Determined that no deficiencies were identified in the complaint investigation and the COVID-19 focused infection control review.
15 Oct 2020Licensure
15 Oct 2020Licensure
Found no deficiencies related to infection control during a focused COVID-19 survey.
15 Oct 2020Licensure
15 Oct 2020Licensure
Found no deficiencies.
02 Sept 2020Complaint
02 Sept 2020Complaint
Found no deficiencies following complaint and COVID-19 infection control surveys.
22 Jul 2020Complaint
22 Jul 2020Complaint
Investigated a complaint and COVID-19 focused infection prevention assessment; found no deficiencies.
23 Apr 2020Complaint
23 Apr 2020Complaint
Concluded that no deficiencies were identified related to the complaint or the COVID-19 infection control survey.
03 Apr 2020Licensure
03 Apr 2020Licensure
Concluded that no deficiencies were identified in the infection control survey.
27 Feb 2020Complaint
27 Feb 2020Complaint
Investigated a complaint and found no deficiencies. The investigation took place on February 26–27, 2020.
13 Dec 2019Revisit
13 Dec 2019Revisit
Verified that all previously cited deficiencies were corrected and no new noncompliance was found on the follow-up. The site is in compliance with all regulations surveyed.
13 Dec 2019Revisit
13 Dec 2019Revisit
Verified prior deficiencies were corrected and no new noncompliance was found.
13 Nov 2019Complaint
13 Nov 2019Complaint
Determined that no deficiencies were identified in the complaint investigation.
30 Oct 2019Complaint
30 Oct 2019Complaint
Found deficiencies in wound care documentation for one resident, including missing surgical wound assessments and lack of ongoing evaluation.
CFR 483.25Quality of Care
25 Oct 2019Complaint
25 Oct 2019Complaint
Investigated a complaint and found violations related to CPR policies and advance directives, including failure to initiate CPR for a resident who elected full code, resulting in the resident's death.
§483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
§483.24(a)(3)Cardio-Pulmonary Resuscitation (CPR)
21 Aug 2019Complaint
21 Aug 2019Complaint
Investigated medication-related concerns and found that 2 of 11 sampled residents experienced significant medication errors, including missed Lovenox doses and delays in Coumadin adjustments, baclofen dosing not updated timely, and untimely Rocephin administration.
42 CFR 483.45(f)(2)Residents are free of significant medication errors
03 Jul 2019Complaint
03 Jul 2019Complaint
Found no deficiencies.
01 Jul 2019Revisit
01 Jul 2019Revisit
Verified that all prior deficiencies were corrected and found no new noncompliance.
11 Jun 2019Complaint
11 Jun 2019Complaint
Concluded no deficiencies were identified in the complaint investigation.
29 May 2019Complaint
29 May 2019Complaint
Found no deficiencies identified in the complaint investigation.
17 May 2019Revisit
17 May 2019Revisit
Verified prior deficiencies were corrected and compliance was restored.
16 Apr 2019Complaint
16 Apr 2019Complaint
Investigated the complaint and found no deficiencies.
11 Apr 2019Complaint
11 Apr 2019Complaint
Multiple deficiencies were found across resident rights, environment, care planning, staffing, hygiene, and infection control, indicating broad lapses in dignity, safety, and quality of care.
§483.10(a)(1) §483.10(a)(2) §483.10(b)(1) §483.10(b)(2)Resident Rights/Exercise of Rights
§483.21(b)(2)(i)-(iii)Care Plan Timing and Revision
§483.21(b)(3)(ii)Qualified Persons
§483.24(a)(2)ADL Care Provided for Dependent Residents
§483.25(b)(1)(i)-(ii)Quality of Care
§483.25(b)(1)(ii) and §483.25(b)(2)Treatment/Svcs to Prevent/Heal Pressure Ulcer
§483.25(e)(1)-(3)Bowel/Bladder Incontinence, Catheter, UTI
§483.35(a)(1)-(2)Sufficient Nursing Staff
§483.45(g)-(h)(1)-(2)Pharmacy Services
§483.45(g)-(h)(1)-(2)Label/Store Drugs and Biologicals
§483.60(i)Food safety requirements
§483.80(a)-(f)Infection Control
§483.80(a)(3)Antibiotic Stewardship Program
11 Apr 2019Licensure
11 Apr 2019Licensure
Concluded compliance with State requirements; no deficiencies identified.
09 Apr 2019Life Safety
09 Apr 2019Life Safety
Found that non-hospital grade receptacles in patient care areas had not been tested within the past 12 months, indicating a deficiency in electrical systems maintenance.
NFPA 99, 2012 edition; Sections 6.3.4.1.3; 6.3.3.2Electrical Systems - Maintenance and Testing
11 Dec 2018Revisit
11 Dec 2018Revisit
Verified compliance; all prior deficiencies were corrected and no new noncompliance was found.
12 Oct 2018Complaint
12 Oct 2018Complaint
Investigated a complaint and found multiple deficiencies related to residents' rights, transfers/discharges, and the facility's handling of resident environments and services.
§483.10(a)(2); §483.10(b); §483.10(c)(1)-(6)Resident rights
§483.70(l)Transfers and discharges
§483.25(d); §483.25(e)Resident environment and dignity; basic needs
—
§483.10; §483.75Rights and responsibilities; quality of care
12 Oct 2018Licensure
12 Oct 2018Licensure
Found no deficiencies. The licensing survey determined compliance with state requirements.
10 Oct 2018Life Safety
10 Oct 2018Life Safety
Determined the site was in compliance with all requirements.
04 Apr 2018Complaint
04 Apr 2018Complaint
Investigated a complaint and concluded that no deficiencies were identified.
15 Feb 2018Complaint
15 Feb 2018Complaint
Investigated the complaint and found no deficiencies.
29 Nov 2017Life Safety
29 Nov 2017Life Safety
Investigated several deficiencies including emergency lighting, sprinkler and fire alarm systems, HVAC, and evacuation planning. Found multiple violations requiring corrective action.
NFPA 101Fire Alarm System - Testing and Maintenance
NFPA 13; NFPA 101Sprinkler System - Installation
NFPA 101; NFPA 90AHVAC
NFPA 101Evacuation and Relocation Plan
20 Nov 2017Revisit
20 Nov 2017Revisit
Concluded that all prior deficiencies were corrected and no new noncompliance was found; the site was in compliance with all regulations surveyed.
20 Nov 2017Revisit
20 Nov 2017Revisit
Investigated the previous deficiencies and found no current noncompliance. All previously cited deficiencies were corrected.
20 Nov 2017Revisit
20 Nov 2017Revisit
Found no deficiencies. A revisit survey conducted on 11/20/17 found all prior deficiencies corrected and no new noncompliance.
20 Nov 2017Revisit
20 Nov 2017Revisit
Investigated a follow-up visit addressing prior deficiencies; all prior deficiencies were corrected and no new noncompliance was found.
03 Nov 2017Life Safety
03 Nov 2017Life Safety
Identified failures in protecting potable water and in plumbing-related life-safety compliance, with aerators found across the facility and incomplete validation of certain systems.
2006 IMC, Section 603.17; 2006 IBC, Section 1020.5Continued From page 2 – System not validated via test and balance report
Wyoming Rules and Regulations for Licensure of Nursing Care Facilities, Chapter 3; Construction Rules and Regulations; 2006 IPC Section 411.1IPC Life Safety - Int'l Plumbing Code
Investigated a complaint about care quality and found multiple deficiencies in nursing and pharmaceutical services, including inadequate pain management, medication regimen follow-through, and medication storage/administration practices.
Investigated deficiencies identified during the survey; concerns included resident sample lists, admissions policies, grievance handling, and daily operations.
03 Oct 2017Life Safety
03 Oct 2017Life Safety
Several life-safety code deficiencies were identified, including problems with means of egress, door hardware and signage, emergency lighting, and annual fire door assembly inspections. Multiple items required corrective action and ongoing monitoring.
NFPA 101, 2012; Sections: 19.2.2.2; 7.2.2.1Means of egress not maintained
NFPA 101, 2012; Sections: 9.7; 9.7.9Electrical Systems – Other
16 Feb 2017Revisit
16 Feb 2017Revisit
Identified six CMS deficiencies and completed corrective actions by 12/30/2016; follow-up confirmed compliance.
483.10(j)(2)-(4)
483.21(b)(3)(ii)
483.45(a)(b)(1)
483.80(a)(1)(2)(4)(e)(f)
483.50(a)(1)
483.70(i)(1)(5)
16 Feb 2017Complaint
16 Feb 2017Complaint
Found no deficiencies. The complaint survey conducted in response to intake #WYO0002359 concluded the licensee was in compliance with the applicable requirements.
13 Jan 2017Revisit
13 Jan 2017Revisit
Found no deficiencies during the follow-up visit.
08 Dec 2016Complaint
08 Dec 2016Complaint
Identified deficiencies across multiple operational areas and required corrective actions.
10 Nov 2016Complaint
10 Nov 2016Complaint
Identified deficiencies in discharge notice requirements; the notice did not include required information and residents' rights to appeal were not properly described.
Type AF203Notice Requirements before Transfer/Discharge
10 Nov 2016Revisit
10 Nov 2016Revisit
Identified multiple life-safety-code deficiencies with corrective actions required; some items show completion and a waiver was noted for one item.
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
LSC / NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
10 Nov 2016Revisit
10 Nov 2016Revisit
Found no deficiencies. Follow-up confirmed corrections from a prior survey.
07 Nov 2016Revisit
07 Nov 2016Revisit
Verified corrections were completed for previously cited deficiencies.
483.10(b)(2)
483.15(a)
483.15(c)(6)
483.15(h)(2)
483.25
483.25(h)
483.35(d)(1)-(2)
483.35(i)
483.75(j)(2)(ii)
07 Nov 2016Complaint
07 Nov 2016Complaint
Found no deficiencies identified in the complaint investigation.
09 Sept 2016Licensure
09 Sept 2016Licensure
Investigated and found no deficiencies; a survey conducted 2016-09-06 through 2016-09-09 determined compliance with state requirements.
09 Sept 2016Complaint
09 Sept 2016Complaint
Investigated deficiencies in resident care, safety, and facility operations; multiple issues were documented during the review.
07 Sept 2016Life Safety
07 Sept 2016Life Safety
Observed issues with an eyewash station including insufficient water pressure and missing spray heads, and a missing temperature regulating device per plumbing code.
2006 IPC ANSI Z358.1IPC Life Safety - Intl Plumbing Code
2006 IPC ANSI Z358.1IPC Life Safety - Intl Plumbing Code
07 Sept 2016Life Safety
07 Sept 2016Life Safety
Investigated safety concerns with egress and related equipment; found deficiencies in exit signage and egress components requiring corrective actions.
Type A2000 NFPA 101 Life Safety CodeExit access/egress deficiencies
25 Mar 2016Revisit
25 Mar 2016Revisit
Verified that previously reported deficiencies were corrected and completed on the listed dates.
05 Feb 2016Complaint
05 Feb 2016Complaint
Found deficiencies in skin integrity care and wound management, including missed treatments and gaps in documentation. The facility also had ongoing issues with care planning and staff education related to wound care.
—INITIAL COMMENTS / overall compliance
—Continued From page 2 – wound care administration
—Continued From page 3 – wound care management plan
11 Dec 2015Revisit
11 Dec 2015Revisit
Verified that previously cited deficiencies were corrected and the follow-up occurred. The revisit indicated substantial compliance with the applicable requirements.
483.12(a)(4)-(6)
483.65
483.70(h)
483.70(h)(3)
483.75(k)(1)
483.25(h2)
483.25(a)(3)
483.60(a)
11 Dec 2015Revisit
11 Dec 2015Revisit
Verified corrections completed for previously cited deficiencies.
Ch 11 Sec 5 (b)(iv)Ch 11 Sec 5 (b)(iv)
Ch 11 Sec 6 (b)(iii)Ch 11 Sec 6 (b)(iii)
Ch 11 Sec 9 (c)(iv)Ch 11 Sec 9 (c)(iv)
30 Nov 2015Revisit
30 Nov 2015Revisit
Verified that required corrections were completed after the revisit; no deficiencies cited.
12 Nov 2015Revisit
12 Nov 2015Revisit
Investigated deficiency found related to transfilling oxygen; staff did not consistently use PPE during transfilling and hazard awareness was insufficient.
NFPA 101 Life Safety Code, Section 19.3.2.4Life Safety Code deficiency – Transfilling of oxygen PPE
03 Sept 2015Licensure
03 Sept 2015Licensure
Investigative findings show that the facility did not properly notify residents or their families about transfers/discharges and failed to document the notices as required.
483.12(a)(4)Notice Requirements Before Transfer/Discharge
03 Sept 2015Licensure
03 Sept 2015Licensure
Identified deficiencies in TB testing for staff, restorative nursing care for residents with movement limitations, and dietary manager qualifications.
—TB testing of employees prior to resident contact
—Restorative nursing care for residents with ROM limitations
—Dietary manager qualifications
31 Aug 2015Life Safety
31 Aug 2015Life Safety
Found several life-safety deficiencies including doors without self-closing devices, obstructions in egress paths, and missing ceiling tiles; oxygen equipment outlets were improperly wired.
—Corridor door lacking self-closing device
—Stairwell obstruction and door hardware issue
—Kitchen doors lack self-closing devices
—Missing ceiling tiles
—Missing ceiling tiles in multiple areas
—Oxygen concentrators on non-medical power taps
—Continued: Oxygen equipment wired to non-medical outlets
29 May 2015Revisit
29 May 2015Revisit
Identified deficiencies related to residents' rights and quality of care; corrections completed.
483.13(c)(1)(ii)-(iii), (c)(2)-(4)Resident rights
483.25(a)(3)Quality of care
19 Mar 2015Complaint
19 Mar 2015Complaint
Found deficiencies related to investigation of alleged violations and to residents' personal care and hygiene, with multiple citations.
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24 Nov 2014Revisit
24 Nov 2014Revisit
Verified no deficiencies were found on the 2014 revisit; prior deficiencies appeared corrected.
24 Nov 2014Revisit
24 Nov 2014Revisit
Found no deficiencies.
20 Nov 2014Revisit
20 Nov 2014Revisit
Identified a deficiency cited under federal regulation; correction completed.
483.25(m)(1)
30 Oct 2014Revisit
30 Oct 2014Revisit
Identified life-safety deficiencies: corridor door hardware inadequate and missing documentation for fire alarm testing.
NFPA 101 Life Safety Code StandardExit access and door hardware
NFPA 101 Life Safety Code StandardFire alarm system testing documentation
30 Oct 2014Revisit
30 Oct 2014Revisit
Discovered life-safety deficiencies regarding eyewash stations; tepid water was not provided through compliant ASSE 1071 mixing valves at multiple locations.
Found deficiencies in medication administration and resident care with required corrections.
06 Aug 2014Life Safety
06 Aug 2014Life Safety
Identified life-safety deficiencies and maintenance issues, including doors that won’t latch or resist smoke, missing emergency lighting documentation, and related corrective actions.
Type ANFPA 101 LIFE SAFETY CODE STANDARDCorridor doors not providing resistance to passage of smoke
Type ANFPA 101 LIFE SAFETY CODE STANDARDCorridor door latch not maintained; door not closing properly
Type ANFPA 101 LIFE SAFETY CODE STANDARDDocumentation of monthly and annual emergency lighting tests
Type ANFPA 101 LIFE SAFETY CODE STANDARDSecured unit corridor doors not latched
06 Aug 2014Life Safety
06 Aug 2014Life Safety
Identified deficiencies related to life-safety and facility operations with ongoing issues from prior pages.
01 Aug 2014Complaint
01 Aug 2014Complaint
The inspection identified deficiencies in medication management and resident care, with multiple observations indicating gaps in documentation and adherence to orders.
483.25(m)(2)Residents free of medication errors
01 Aug 2014Complaint
01 Aug 2014Complaint
Investigated a complaint alleging deficiencies in resident dignity and overall care planning, with observed gaps in how residents were treated and in the care documentation.
Type A—Dignity and rights of residents
01 Aug 2014Licensure
01 Aug 2014Licensure
Found substantial compliance with state requirements; no deficiencies cited.
21 Jul 2014Revisit
21 Jul 2014Revisit
Identified a deficiency requiring corrective action; the correction was completed.
483.30(a) LSCLife Safety Code
05 Jun 2014Revisit
05 Jun 2014Revisit
Investigated deficiencies in bathing care; a resident with severe cognitive impairment did not receive showers and baths as scheduled, and staffing appeared insufficient to provide needed care.
483.20(d)(3), 483.10(k)(2)Shower/bath scheduling and bathing assistance
483.20(k)(3)(i)Inadequate staffing affecting care provision
23 Apr 2014Complaint
23 Apr 2014Complaint
Found deficiencies in resident care planning, weight management, and monitoring with issues in care documentation and adherence to care plans.
05 Mar 2014Complaint
05 Mar 2014Complaint
Found no deficiencies following the complaint investigation.
03 Jan 2014Revisit
03 Jan 2014Revisit
Verified that previously cited deficiencies were corrected and completed; no uncorrected deficiencies were found.
02 Jan 2014Revisit
02 Jan 2014Revisit
Investigated deficiencies identified in the prior review and confirmed corrections were completed.
483.15(a)
483.20(d), 483.20(k)(1)
483.25(d)
483.25(h)
04 Oct 2013Licensure
04 Oct 2013Licensure
Identified a deficiency in governance due to the acting administrator not being licensed by the state; interviews and licensure review showed the administrator had not completed licensure.
Type ACh 11 Sec 5 (a)(vi)Governing Body and Administration
04 Oct 2013Complaint
04 Oct 2013Complaint
Investigated a Wyoming case and found multiple deficiencies related to fall risk management, resident care, and record-keeping.
—Summary statement of deficiencies
—Continued from page 3 – Falls risk
—Program/Interventions documentation
—Transfer/fall-related records
—Data gathering and analysis for falls
05 Sept 2013Complaint
05 Sept 2013Complaint
Investigated the complaint. Found no deficiencies.
23 Jul 2013Complaint
23 Jul 2013Complaint
Identified a deficiency in maintaining a safe, clean, and homelike environment due to persistent odors in multiple resident areas.
Investigated a complaint and found a deficiency related to maintaining a safe, clean, comfortable and homelike environment due to persistent odors and unclean bathrooms observed during the survey.
—Safe/Clean/Comfortable/Homelike Environment
03 Jul 2013Revisit
03 Jul 2013Revisit
Found no deficiencies.
09 May 2013Complaint
09 May 2013Complaint
Identified multiple deficiencies in medication administration, housekeeping/maintenance, and resident care processes, indicating noncompliance with regulatory standards.
Type AF-176Resident Self-Administration of Drugs If Deemed Safe
Type AF-253Housekeeping and Maintenance Services
Type AF-272Comprehensive Assessments
Type AF-281Services Provided Meet Professional Standards
Type AF-282Services by Qualified Persons/Per Care Plan
09 May 2013Licensure
09 May 2013Licensure
Determined compliance with state requirements after a survey conducted May 6-9, 2013, with no deficiencies cited.
07 May 2013Life Safety
07 May 2013Life Safety
The inspection identified multiple life-safety deficiencies including door hardware and smoke barriers, sprinkler head revisions, oxygen storage, and several other safety-related practices. Repeat deficiencies were cited across several pages with corrective actions planned.
NFPA 101 Life Safety Code StandardNFPA 101 Life Safety Code Standard
NFPA 101 Life Safety Code StandardCorrective Action(s) for Those Residents Found to Have Been Affected by the Deficient Practice:
NFPA 101 Life Safety Code StandardNFPA 101 Life Safety Code Standard
NFPA 101 Life Safety Code StandardNFPA 101 Life Safety Code Standard
NFPA 101 Life Safety Code StandardCorrective Action(s) for Those Residents Found to Have Been Affected by the Deficient Practice:
NFPA 101 Life Safety Code StandardCorrective Action(s) for Those Residents Found to Have Been Affected by the Deficient Practice:
NFPA 101 Life Safety Code StandardCorrective Action(s) for Those Residents Found to Have Been Affected by the Deficient Practice:
NFPA 101 Life Safety Code StandardCorrective Action(s) for Those Residents Found to Have Been Affected by the Deficient Practice:
NFPA 101 Life Safety Code StandardCorrective Action(s) for Those Residents Found to Have Been Affected by the Deficient Practice:
11 Apr 2013Revisit
11 Apr 2013Revisit
Investigated a post-certification revisit conducted on 2013-04-11 following a prior survey. No deficiencies were cited in the accessible sections.
21 Feb 2013Licensure
21 Feb 2013Licensure
Identified deficiencies in pain management documentation and post-fall assessments, including inadequate evaluation of medication effectiveness and staff competency in fall-related evaluations.
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23 Aug 2012Complaint
23 Aug 2012Complaint
Concluded that no deficiencies were identified in the complaint investigation conducted on 8/23/12.
16 Aug 2012Revisit
16 Aug 2012Revisit
Cited deficiencies were identified during the revisit. Several items related to regulatory standards were noted.
16 Aug 2012Revisit
16 Aug 2012Revisit
Verified that previously reported deficiencies were corrected and actions completed. No new deficiencies were cited.
16 Aug 2012Revisit
16 Aug 2012Revisit
Investigated follow-up on prior deficiencies; corrections were completed.
21 Jun 2012Complaint
21 Jun 2012Complaint
Identified deficiencies in the assessment and care planning process, showing failure to develop resident-specific, measurable goals in comprehensive assessments for several residents.
—Comprehensive Assessments
21 Jun 2012Licensure
21 Jun 2012Licensure
Investigation found hot water temperatures in several resident rooms exceeded the maximum allowed, indicating a deficiency in the physical environment standards.
Wyoming Rules and Regulations for Nursing Homes, Chapter 11, Section 6 (Physical Environment)Physical Environment
20 Jun 2012Life Safety
20 Jun 2012Life Safety
Observed deficiencies in life-safety features, including a non-continuous fire barrier with a self-closing door that would not latch, and issues with penetrations and sprinkler heads.
NFPA 101 Life Safety Code StandardContinued From page 1
NFPA 101 Life Safety Code StandardContinued From page 2
NFPA 101 Life Safety Code StandardContinued From page 3
01 Dec 2011Complaint
01 Dec 2011Complaint
Investigated the complaint; found no deficiencies identified.
03 Aug 2011Revisit
03 Aug 2011Revisit
Identified deficiencies in life-safety code compliance that were corrected; a follow-up reviewed the corrections.
NFPA 101Life Safety Code
NFPA 101Life Safety Code
NFPA 101Life Safety Code
22 Jul 2011Revisit
22 Jul 2011Revisit
Verified corrections were completed for identified deficiencies during a follow-up visit. Corrections were completed on 07/10/2011.
483.15(h)(2)Life Safety Code
483.15(h)(2)Life Safety Code
483.20(d)(3), 483.10(k)(2)Life Safety Code
483.25(c)Life Safety Code
483.25Life Safety Code
483.25(h)Life Safety Code
483.25(a)(3)Life Safety Code
26 May 2011Complaint
26 May 2011Complaint
Identified multiple deficiencies in housekeeping, resident rights, safety, and care practices, including inadequate housekeeping and maintenance, insufficient involvement in care planning, unsafe environments, and lapses in medical administration and monitoring.
483.15(h)(2)Housekeeping & Maintenance Services
483.20(d)(3), 483.10(k)(2)Right to Participate in Planning Care
483.25(h)Free of Accident Hazards/Supervision/Devices
—Continued From page 3 – Urinary Tract Infections
—Continued From page 5 – Incontinence Care
—Continued From page 7 – Pressure Ulcers Prevention/Care
483.75(1) ADMINISTRATIONAdministration
26 May 2011Licensure
26 May 2011Licensure
Found no deficiencies and determined the facility was in compliance with state requirements.
26 May 2011Licensure
26 May 2011Licensure
Found no deficiencies.
24 May 2011Life Safety
24 May 2011Life Safety
Identified multiple life-safety deficiencies, including issues with smoke-detection visibility, sprinkler system maintenance, and the storage/handling of gases. The findings indicate non-compliance with required safety standards.
NFPA 101 Life Safety Code StandardLine-of-sight flash not simultaneous
NFPA 101 Life Safety Code StandardSprinkler system maintenance/coverage
NFPA 101 Life Safety Code StandardOxygen transfer/storage safety
28 Dec 2010Complaint
28 Dec 2010Complaint
Investigated the complaint and concluded no deficiencies were identified.
04 Aug 2010Licensure
04 Aug 2010Licensure
Investigated and identified deficiencies that required correction during the follow-up review.
30 Jul 2010Revisit
30 Jul 2010Revisit
Investigated prior deficiencies and verified corrections were completed.
21 May 2010Licensure
21 May 2010Licensure
Investigated deficiencies related to resident rights and quality of life with multiple violations found; corrective actions were implemented.
—Right to be Free From Physical Restraints
—Care and Environment Promotes Quality of Life
—Continued From page 6
—Activities
—Provision of Medically Related Social Services
20 May 2010Licensure
20 May 2010Licensure
Identified non-compliance with state nursing home regulations after a survey conducted in May 2010.
—Licensing Regulations for Nursing Homes
20 May 2010Licensure
20 May 2010Licensure
Investigated a complaint and found deficiencies related to resident rights and care processes, including restraint use and care planning.
18 May 2010Life Safety
18 May 2010Life Safety
Investigated life-safety concerns with storage practices and obstructed egress; multiple deficiencies were found requiring corrective actions.
NFPA 101 Life Safety Code StandardStorage within smoke compartments
NFPA 101 Life Safety Code StandardConstruction and egress requirements
NFPA 101 Life Safety Code StandardCorrective action and system maintenance
04 Jun 2009Revisit
04 Jun 2009Revisit
Investigated and found deficiencies in several regulatory areas; corrections were completed. Cited areas included resident rights, nursing services, comprehensive assessment and care planning, discharge planning, dietary and quality of life.
Type A483.15(a)Resident rights
483.15(h)(2)Resident rights
483.20(k)(3)(i)Nursing services
Type A483.25(a)Comprehensive assessment of residents and care planning
483.25(a)(3)Comprehensive assessment of residents and care planning
483.25(d)Discharge planning
483.70(h)Quality of life
483.65(b)(3)Dietary
483.75Physician services
22 May 2009Revisit
22 May 2009Revisit
Investigated the follow-up visit and found no deficiencies.
19 May 2009Revisit
19 May 2009Revisit
Concluded that corrective actions were completed and compliance achieved.
30 Mar 2009Life Safety
30 Mar 2009Life Safety
Identified deficiencies where required construction plans and an infection control risk assessment were not submitted before starting construction; observed ongoing electrical work without proper approval.
—State Rules and Regulations for Construction/Remodeling and Infection Control Risk Assessment
30 Mar 2009Life Safety
30 Mar 2009Life Safety
Observed deficiencies include exit signs not illuminated, monthly portable extinguisher inspections not performed on two floors, and improper use of extension cords.
NFPA 101 Life Safety CodeExit signs illumination
NFPA 101 Life Safety CodePortable fire extinguishers monthly inspections
NFPA 101 Life Safety CodeUse of extension cords/surge protectors
27 Mar 2009Licensure
27 Mar 2009Licensure
Investigated case resulted in multiple deficiencies found in dignity, care planning, incontinence management, infection control, staffing, and the facility’s environment.
483.15(a)Dignity
—Care Plans/Professional Standards
—Urinary Incontinence
—Urinary Incontinence
—Nurse Staffing
—Preventing Spread of Infection
—Laboratory Services
—Other Environmental Conditions
27 Mar 2009Licensure
27 Mar 2009Licensure
Found no deficiencies identified after a recertification survey conducted March 24–27, 2009.
29 Jan 2009Complaint
29 Jan 2009Complaint
Investigated the complaint and found no deficiencies.
30 Dec 2008Revisit
30 Dec 2008Revisit
Identified multiple deficiencies cited under federal requirements and documented that corrective actions were completed during the 2008 follow-up visit.
483.20, 483.20(b)
483.20(k)(3)(ii)
483.25(c)
483.25(d)
483.25(m)(1)
483.25(n)
483.60(a),(b)
30 Dec 2008Revisit
30 Dec 2008Revisit
Investigated an earlier issue and performed a post-certification revisit; uncorrected deficiencies were identified.
07 Nov 2008Licensure
07 Nov 2008Licensure
Determined no deficiencies were identified during the state licensure survey.
06 Nov 2008Complaint
06 Nov 2008Complaint
Investigators found deficiencies in residents' assessments and care planning, including missing bowel and pressure‑sore assessments, inadequate urinary incontinence management, and medication management issues affecting several residents.
—Comprehensive Assessments
—Pressure Sores
—Urinary Incontinence
—Medication Errors
—Identification of Other Residents Having the Potential to be Affected by the Same Deficient Practice
—Pharmacy Services
04 Nov 2008Life Safety
04 Nov 2008Life Safety
Found deficiencies in fire safety measures, including holes in smoke compartments and missing annual emergency lighting tests.
—Smoke barrier integrity and wall penetrations
—Emergency lighting/testing (Life Safety Code)
—Electrical wiring and use of extension cords
17 Sept 2007Revisit
17 Sept 2007Revisit
Investigated deficiencies identified during a follow-up; confirmed corrections were completed on 2007-09-17.
29 Aug 2007Revisit
29 Aug 2007Revisit
Found deficiencies in resident privacy and in care planning and documentation for resident care and supervision.
483.10(b)Privacy and Confidentiality
483.10(b)Comprehensive care plans (behavior interventions)
—Comprehensive care plans
—Comprehensive physician progress notes
29 Aug 2007Complaint
29 Aug 2007Complaint
Investigated a complaint and found no deficiencies.
21 Jun 2007Complaint
21 Jun 2007Complaint
Investigated deficiencies related to resident dignity and care, with multiple noted areas where care practices did not meet expected standards.
42 CFR 483.10Dignity and respect
16 Jan 2007Complaint
16 Jan 2007Complaint
Investigated a complaint and found no deficiencies identified.
02 Nov 2006Revisit
02 Nov 2006Revisit
Identified multiple deficiencies during a follow-up visit; several federal requirements were not met.
483.10(b)(11)
483.13(c)
483.20(b)(3)
483.25
483.20(k)(3)(i)
483.75(i)(1)
483.25(k)
483.65(a)
483.65(c)
483.75(i)(1)
483.75(k)(2)(iv)
02 Nov 2006Complaint
02 Nov 2006Complaint
Investigated a complaint; found no deficiencies.
24 Aug 2006Revisit
24 Aug 2006Revisit
Verified corrections of previously reported deficiencies and found no new deficiencies.
03 Aug 2006Complaint
03 Aug 2006Complaint
Identified deficiencies in resident assessment, care planning and delivery, and staffing levels during the investigation.
—Notification of changes in resident's condition
—Comprehensive Care Plans
—Comprehensive Assessments
—Nursing Services - Sufficient Staff
—Quality of Care / Resident Well-being
—Rehabilitation/Resident Care Services
28 Jun 2006Life Safety
28 Jun 2006Life Safety
The inspector identified several life-safety deficiencies related to interior finishes, fire protection systems, lighting, electrical wiring, and door hardware. The findings indicate non-compliance with NFPA 101 Life Safety Code requirements.
NFPA 101 LIFE SAFETY CODE STANDARDInterior finishes (corridors/exitways)
NFPA 101 LIFE SAFETY CODE STANDARDDoor hardware/closures (self-closing devices)
NFPA 101 LIFE SAFETY CODE STANDARDFire alarm system (installation/maintenance)
NFPA 101 LIFE SAFETY CODE STANDARDEmergency lighting (battery backup)
NFPA 101 LIFE SAFETY CODE STANDARDEmergency lighting (1.5 hour duration)
NFPA 101 LIFE SAFETY CODE STANDARDFire safety barrier/wiring (smoke barriers and electrical penetrations)
NFPA 101 LIFE SAFETY CODE STANDARDElectrical wiring and equipment
30 May 2006Revisit
30 May 2006Revisit
Cited deficiencies with required corrections; follow-up confirmed corrections completed.
483.20, 483.20(b)
483.25(a)(3)
483.750(1)
30 May 2006Complaint
30 May 2006Complaint
Investigated a complaint; found no deficiencies identified.
30 May 2006Revisit
30 May 2006Revisit
Verified corrections from a prior survey were completed and no new deficiencies were found.
13 Apr 2006Complaint
13 Apr 2006Complaint
Identified deficiencies related to safety hazards and improper storage; hazardous items were left unsecured on a ledge in the upper floor areas with additional concerns noted on related units.
—Free of accident hazards
23 Mar 2006Complaint
23 Mar 2006Complaint
Identified deficiencies in comprehensive resident assessments, daily living activities, and clinical record-keeping.
Type A483.20, 483.20(b)Comprehensive Assessments
Type A483.25(a)(3)Activities of Daily Living
Type A483.75(i)(1)Clinical Records
12 Dec 2005Revisit
12 Dec 2005Revisit
Verified that previously identified deficiencies were corrected and follow-up confirmed improvements.
13 Oct 2005Complaint
13 Oct 2005Complaint
Identified deficiencies in care plans and their implementation, with staff not following residents' written plans for care and toileting assistance.
403.20(k)(3)(vii)COMPREHENSIVE CARE PLANS
01 Sept 2005Revisit
01 Sept 2005Revisit
Investigated a complaint and identified multiple regulatory deficiencies across resident rights and care standards. Corrections were completed.
483.10(b)(11)
483.15(a)
483.15(h)(2)
483.25(a)(2)
483.20(k)(3)
483.25(d)
01 Sept 2005Complaint
01 Sept 2005Complaint
Investigated a complaint survey conducted 8/31/05 through 9/1/05; found no deficiencies.
28 Jul 2005Revisit
28 Jul 2005Revisit
Identified deficiencies and confirmed corrective actions completed.
30 Jun 2005Licensure
30 Jun 2005Licensure
Identified a deficiency in dental services due to no current signed dental contract and potential impact on residents.
Section 14 Dental ServicesDental Services
30 Jun 2005Licensure
30 Jun 2005Licensure
Investigated a resident-care concern revealing multiple deficiencies in medical monitoring, dignity and respect, daily living assistance, and care planning across several areas.
483.10(b)(11)NOTIFICATION OF CHANGES IN BLOOD SUGAR
483.15(a)DIGNITY
483.15(a)DIGNITY
483.30(d) and 483.30(k)(1)COMPREHENSIVE CARE PLANS
483.25(a)(2)ACTIVITIES OF DAILY LIVING
483.25(k)COMPREHENSIVE CARE PLANS
483.25(k)SPECIAL NEEDS
483.30(a)NURSING SERVICES - SUFFICIENT STAFF
483.25(k)SPECIAL NEEDS
483.25(k)SPECIAL NEEDS
03 Jun 2005Life Safety
03 Jun 2005Life Safety
Investigated deficiencies in life-safety and electrical systems with multiple violations identified related to corridor accessibility, electrical wiring, and posted safety signage.
Type ANFPA 101 LIFE SAFETY CODE STANDARDCorridor/egress obstruction
Type ANFPA 101 LIFE SAFETY CODE STANDARD; NFPA 70Electrical wiring and equipment; GFCI requirement
Type ANFPA 101 LIFE SAFETY CODE STANDARDLife safety standard deficiency (continued)
Type ANFPA 101 LIFE SAFETY CODE STANDARDSafety equipment/egress and related provisions
Type ANFPA 101 LIFE SAFETY CODE STANDARDContinued deficiency narrative
Type ANFPA 101 LIFE SAFETY CODE STANDARDNO SMOKING and oxygen storage signage
11 May 2005Complaint
11 May 2005Complaint
Investigated a complaint; found no deficiencies.
15 Feb 2005Complaint
15 Feb 2005Complaint
Investigated housekeeping and maintenance practices; found daily cleaning and dusting were not consistently performed, with litter and dust observed in multiple rooms.
483.15(l)(2) ENVIRONMENTENVIRONMENT
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