I trust Polaris with my mother - the knowledgeable, compassionate staff (Stephanie Gonzales, Eric and Corina stood out) consistently go above and beyond. The facility is clean and welcoming, meals are homemade and tasty, therapy and activities are excellent, and the new ownership/staff dynamic feels attentive; I highly recommend it.
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
Mental wellness program
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
Memory care community services
Mild cognitive impairment
Specialized memory care programming
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
3.96·(49)
Overall rating
5
4
3
2
1
Care
3.8
Staff
4.1
Meals
4.7
Amenities
3.7
Value
3.0
Pros
Compassionate and attentive nursing staff
Knowledgeable and caring CNAs
Skilled rehabilitation services (PT/OT/SLP)
Responsive call-button and medication support
Engaging recreational and exercise programming
Active social atmosphere with resident engagement
Homemade, varied dining options
Outdoor spaces and music during meals
Welcoming, family-oriented reception and staff
Ongoing facility updates and renovations
Cognitively trained staff and teaching-program involvement
Accessible activity calendar and programming
Cons
Inconsistent sanitation and incontinence-care practices
Pest-control deficiencies in some areas
Variable staff responsiveness and communication
Staff conduct and tone
Short staffing and turnover pressures
Inconsistent facility maintenance across rooms
Perceived emphasis on financial priorities over care
Gaps in family communication and pharmacy coordination
End-of-life care communication and classification
Allegations of falsified positive reviews
Summary of reviews
Reviewer sentiment for Polaris Rehabilitation and Care Center is mixed, with a clear split between families praising clinical and social programming and others expressing serious operational concerns. Positive comments center on the clinical team and rehabilitation services: many reviewers highlight compassionate nurses and CNAs, prompt call-button and medication responses, and a therapy team regarded as skilled and supportive for recovery. The facility's rehabilitative offerings (PT/OT/SLP) and personalized therapy attention are consistent strengths cited by families and residents.
Social and quality-of-life offerings receive favorable notice as well. Multiple accounts describe an active, engaged resident population with regular recreational and exercise activities, music during meals, outdoor areas, and frequent social events. Dining is frequently described as homemade and varied, and the facility layout (including multiple dining areas) supports communal interaction. Several reviewers also note a welcoming reception, family-oriented staff, and the presence of teaching-program involvement that brings cognitively trained personnel into care.
At the same time, a number of reviewers report operational weaknesses that warrant consideration. Cleanliness and sanitation are inconsistent across accounts, including specific incontinence-care and odor concerns and isolated pest-control issues. Staffing stability and responsiveness are recurring themes: reviewers describe short staffing, variable responsiveness to resident needs, and uneven communication with families and external partners such as pharmacies. There are also concerns about staff conduct and tone in some interactions, plus perceptions that financial considerations are sometimes prioritized over clinical needs. A small set of serious allegations includes concerns about end-of-life communication and claims about the authenticity of some positive reviews.
Management and facility condition also show mixed signals. Several reviewers applaud recent ownership changes, wage increases, staff incentives, and visible renovations that have improved the environment and staff morale. Others describe older rooms that need remodeling and inconsistent maintenance across units. Prospective residents should weigh the visible improvements under new leadership against the noted operational inconsistencies.
For families evaluating Polaris, recommended due diligence includes an in-person tour focusing on cleanliness, room condition, and communal spaces; direct conversations with nursing leadership about staffing ratios, turnover, infection-control and pest-control protocols, and end-of-life care policies; and clarification of pharmacy coordination and family-communication practices. The facility demonstrates strong clinical and social programming in many accounts, but variability in operational execution suggests that individual experiences may differ depending on unit, staffing, and recent management initiatives.
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Medicare Ratings
1·/ 5
Cited by CMS for abuse, or potential for abuse, on its most recent survey cycle.
Overall
Health Inspection
Staffing
Quality Measures
Ratings from the U.S. Centers for Medicare & Medicaid Services (Care Compare). View on Medicare.gov
Location
Polaris Rehabilitation and Care Center is located at 2700 E 12th St, Cheyenne, WY, 82001.
About Polaris Rehabilitation and Care Center
Cheyenne Healthcare Center is a senior living community dedicated to providing quality care and a supportive environment for its residents. The community offers a variety of services for seniors, including independent living, assisted living, memory care, and skilled nursing. The center aims to create a warm and welcoming atmosphere where residents can enjoy a vibrant lifestyle while receiving the assistance they need for daily living activities.
One of the hallmarks of Cheyenne Healthcare Center is its focus on nutritious and enjoyable meals. The community's chefs and meal planners are committed to crafting dishes that strike the right balance of vitamins and minerals, ensuring residents receive healthy, delicious, and satisfying options at every meal. By prioritizing fresh, quality ingredients, the dining experience is designed not only to meet dietary needs but also to excite residents and encourage social interaction during mealtimes.
Cheyenne Healthcare Center also places an emphasis on engaging its residents through a thoughtful range of activities. The community organizes programs that stimulate residents physically, mentally, socially, and emotionally. These activities are designed to foster connections among residents and promote a sense of belonging, purpose, and enjoyment. Whether through exercise classes, creative workshops, games, or special events, the center ensures there are opportunities for everyone to participate and remain active.
The culture at Cheyenne Healthcare Center is characterized by friendliness and kindness, as evidenced by the staff's commitment to creating a joyful and supportive community. Staff members are dedicated to being helpful and attentive to each resident's needs, building strong relationships with residents and their families alike. The atmosphere throughout the center is one of cheerful cooperation, making it a pleasant place for both residents and visitors.
In addition to daily care and engaging activities, Cheyenne Healthcare Center provides specialized memory care services, supporting those living with dementia and related conditions. Residents in need of skilled nursing receive attentive medical care from compassionate professionals, ensuring that each individual's health and well-being are prioritized. Through its personalized approach, Cheyenne Healthcare Center strives to enhance the lives of seniors and provide peace of mind for their families.
People often ask...
Polaris Rehabilitation and Care Center offers assisted living, memory care, and skilled nursing.
There are 4 photos of Polaris Rehabilitation and Care Center on Mirador.
The full address for this community is 2700 E 12th St, Cheyenne, WY 82001.
No, Polaris Rehabilitation and Care Center does not offer respite care.
Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.
Safety & Compliance
In Wyoming, the Department of Health's Healthcare Licensing & Surveys program licenses care facilities and publishes licensure, complaint, and life-safety findings.
License number
nh-192
Facility type
Nursing Home
Inspection Reports
214
Reports
27
Type A Citations
1
Type B Citations
131
Complaints
21
Years
07 Aug 2025Complaint
07 Aug 2025Complaint
Investigated a complaint and found violations related to resident safety and medication management, including a resident-on-resident abuse incident and a fentanyl patch mismanagement leading to overdose.
Type A§483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
§483.45(f)(2)Residents are free of any significant medication errors
12 Dec 2024Revisit
12 Dec 2024Revisit
Found no deficiencies after a follow-up visit; all previously cited issues were corrected.
24 Oct 2024Complaint
24 Oct 2024Complaint
Identified failures to communicate changes in health care appointments to residents or their representatives and to document SARS-CoV-2 test results during an outbreak.
§483.10(f)Self-Determination
§483.80Infection Prevention & Control
21 Oct 2024Revisit
21 Oct 2024Revisit
Verified compliance with all regulations; all previous deficiencies were corrected and no new noncompliance was found.
23 Aug 2024Complaint
23 Aug 2024Complaint
Investigated a complaint about missing tracheostomy care for a resident with a tracheostomy; multiple failures to perform and document ordered care were found across several shifts.
483.25(i)Respiratory care including tracheostomy care and tracheal suctioning
26 Jun 2024Licensure
26 Jun 2024Licensure
Investigated multiple deficiencies related to care planning, patient safety around smoking, dialysis communications, daily staffing postings, and immunization administration.
CFR 483.21(a)(1)-(3)Baseline Care Plan
CFR 483.21(b)(2)(i)-(iii)Care Plan Timing and Revision
CFR 483.25(d)(1)-(2)Free of Accident Hazards/Supervision/Devices
CFR 483.25(l)Dialysis
CFR 483.35(g)(1)-(4)Posted Nurse Staffing Information
CFR 483.80(d)Influenza and Pneumococcal Immunizations
24 Jun 2024Life Safety
24 Jun 2024Life Safety
Identified deficiencies in emergency preparedness and multiple life-safety systems, including alarms, sprinklers, smoke barriers, and electrical safety.
42 CFR 483.73Emergency Preparedness Plan
42 CFR 483.73(c)Emergency Preparedness Communication Plan
NFPA 101; NFPA 72Fire Alarm System - Testing and Maintenance
NFPA 101; NFPA 25Sprinkler System - Maintenance and Testing
NFPA 101, Sections 19.3.7.8; 8.5.4Subdivision of Building Spaces - Smoke Barrier Doors
NFPA 99Health Care Facilities Code - Other
31 May 2024Complaint
31 May 2024Complaint
Found no deficiencies. The complaint investigation did not identify any regulatory violations.
22 Mar 2024Revisit
22 Mar 2024Revisit
Verified all deficiencies were corrected and no new noncompliance was identified.
19 Jan 2024Complaint
19 Jan 2024Complaint
Investigated a complaint and found deficiencies in accident prevention, resident meal choices, and food safety practices.
CFR 483.25(d)(1)-(2)Free of Accident Hazards/Supervision/Devices
CFR 483.60(i)(1)-(2)Food safety – beard and hair restraints
21 Nov 2023Complaint
21 Nov 2023Complaint
Determined that no deficiencies were identified during the complaint investigation.
25 Aug 2023Complaint
25 Aug 2023Complaint
Found no deficiencies identified during the complaint investigation.
28 Jul 2023Revisit
28 Jul 2023Revisit
Verified no deficiencies and continued compliance with applicable regulations.
25 Jul 2023Revisit
25 Jul 2023Revisit
Concluded that all prior deficiencies were corrected and compliance was restored.
25 Jul 2023Revisit
25 Jul 2023Revisit
Verified that previous deficiencies were corrected and no new noncompliance was found.
22 Jun 2023Complaint
22 Jun 2023Complaint
Found deficiencies in resident rights regarding refusing treatment, inappropriate use of restraints, inadequate monitoring of psychotropic medications, and infection control during wound care.
42 CFR 483.10(c)(6)(8)(g)(12)(i)-(v)Resident rights to accept/refuse treatment and advance directives
42 CFR 483.10(e); 42 CFR 483.12(a)(2)Freedom from restraints; abuse prevention
42 CFR 483.45(e)Psychotropic medications monitoring and reduction
42 CFR 483.80Infection prevention and control
22 Jun 2023Licensure
22 Jun 2023Licensure
Concluded compliance with state requirements after the review; no deficiencies cited.
21 Jun 2023Life Safety
21 Jun 2023Life Safety
Found the boiler room contained combustible storage, including a portable air conditioner, in violation of requirements.
2006 International Fire Code 315.2.3Boiler room free of combustible storage
21 Jun 2023Life Safety
21 Jun 2023Life Safety
Regulatory findings identified multiple life safety and utility deficiencies, including absence of a reliability letter for the emergency power fuel supply, improper protection of cooking equipment, sprinkler obstructions, and electrical system hazards.
42 CFR 483.73(e)Emergency and standby power systems
Verified all prior deficiencies were corrected and no new noncompliance was found.
01 Feb 2023Revisit
01 Feb 2023Revisit
Verified that prior deficiencies were corrected and no new noncompliance found.
22 Dec 2022Licensure
22 Dec 2022Licensure
Investigated deficiencies across assessments, care planning, mobility, catheter care, pharmacy, medication storage, food safety, and COVID-19 vaccination management identified during a survey conducted in late 2022.
CFR 483.20(g)Accuracy of Assessments
CFR 483.21(b)(1)(3)Comprehensive Care Plans
CFR 483.21(b)(2)(i)-(iii)Care Plan Timing and Revision
CFR 483.25(c)(1)-(3)Mobility - ROM
CFR 483.25(e)(1)-(3)Incontinence - Catheter/UTI
CFR 483.45(a)-(b)(1-3)Pharmacy Services
CFR 483.45(g)-(h)(1)-(2)Label/Store Drugs and Biologicals
CFR 483.80(i)(1)-(3)COVID-19 Vaccination of Facility Staff
20 Dec 2022Life Safety
20 Dec 2022Life Safety
Investigations found multiple life safety and fire protection deficiencies, including ceiling holes, improper egress hardware, obstructed sprinklers, uninspected extinguishers, portable space heaters, and unsafe gas cylinder storage.
Found no deficiencies identified during the complaint investigation.
22 Aug 2022Revisit
22 Aug 2022Revisit
Concluded that all previously cited deficiencies were corrected and no new noncompliance was found.
22 Aug 2022Revisit
22 Aug 2022Revisit
Found no deficiencies.
10 Aug 2022Revisit
10 Aug 2022Revisit
Verified that all previously cited deficiencies were corrected and compliance was restored.
01 Jul 2022Licensure
01 Jul 2022Licensure
An investigation identified multiple deficiencies across assessment timing, care planning, transfer notices, infection control, medications, nutrition, and COVID-19 procedures.
Identified multiple life safety and emergency preparedness deficiencies, including inadequate drills, obstructed exits, doors not self-closing, excessive ABHR storage, unmaintained fire alarm batteries, compromised corridor separations, and unsealed sprinkler-head openings.
CFR §483.73(d)(2)Emergency preparedness testing
NFPA 101 19.7.3.1; 7.1.10.1Means of Egress - General
NFPA 101: 7.2.1.8.2Doors with Self-Closing Devices
NFPA 101: 19.3.2.3(7); NFPA 30: 9.7.1, 9.7.2Alcohol Based Hand Rub Dispenser (ABHR) storage
NFPA 72; NFPA 70Fire Alarm System - Testing and Maintenance
NFPA 101 19.3.6.2; 19.3.6.2.7Corridors - Construction of Walls
13 Jun 2022Revisit
13 Jun 2022Revisit
Concluded that all previously cited deficiencies were corrected and no new noncompliance was found.
08 Apr 2022Complaint
08 Apr 2022Complaint
Investigated complaints found multiple deficiencies: care plans not updated for changing needs, dehydration management issues, nursing staff competency concerns, and unsecured storage of medications.
483.21(b)(1)Develop/Implement Comprehensive Care Plan
483.25Quality of Care
483.35(a)(3)(4)(c)Nursing Services
483.45(g)(h)(1)(2)Label/Store Drugs and Biologicals
10 Mar 2022Revisit
10 Mar 2022Revisit
Found no deficiencies. The survey confirmed compliance with life safety code requirements.
23 Feb 2022Revisit
23 Feb 2022Revisit
Found no deficiencies.
23 Feb 2022Revisit
23 Feb 2022Revisit
Confirmed no deficiencies cited after a revisit; all previously cited issues were corrected and no new noncompliance was found.
23 Feb 2022Revisit
23 Feb 2022Revisit
Verified that prior deficiencies were corrected and no new noncompliance was found.
10 Feb 2022Complaint
10 Feb 2022Complaint
Found no deficiencies during the complaint investigation.
06 Jan 2022Licensure
06 Jan 2022Licensure
Investigated infection control concerns and found multiple deficiencies in following transmission-based precautions, hand hygiene, PPE use, and equipment disinfection during resident care and hydration activities.
Wyoming Rules and Regulations Chapter 11, Section 6(b)(i)Physical environment; infection control
06 Jan 2022Licensure
06 Jan 2022Licensure
Found multiple deficiencies in resident care planning, bathing, continence, medication management, bed rails, staffing, and infection control.
§483.21(b)(1)Comprehensive Care Plans
§483.21(b)(1)Comprehensive Care Plans
§483.21(b)(2)(i)-(iii)Care Plan Timing and Revision
§483.24(a)(2)ADL Care Provided for Dependent Residents
§483.25(e)Incontinence
§483.25(n)Bed Rails
§483.35(a)(1)-(2) and §483.35(g)Sufficient Nursing Staff
§483.35(g)(1)-(4)Posted Nurse Staffing Information
§483.45(d)Unnecessary Drugs
§483.75(g)QAPI/QAA Improvement Activities
§483.80(a)Infection Prevention & Control
§483.80(a)(3)Antibiotic Stewardship
05 Jan 2022Life Safety
05 Jan 2022Life Safety
Identified multiple life safety deficiencies related to means of egress, egress doors, sprinkler system, curtains, and door tagging.
2012 NFPA 101, Sections: 19.7.3.1; 7.1.10.1Means of Egress - General
2010 NFPA 110, Sections: 8.3.7.1Electrical Systems - Essential Electrical Systems
13 Dec 2021Complaint
13 Dec 2021Complaint
Identified deficiencies in care planning and nutrition management, including failure to complete comprehensive assessments and gaps in weight/nutrition documentation.
483.20(b)(2)(ii)Comprehensive Assessment After Significant Change
Type A483.25(g)(1)-(3)Nutrition/Hydration Status Maintenance
06 Oct 2021Complaint
06 Oct 2021Complaint
Investigated a complaint survey and found no deficiencies identified related to infection control. The survey was prompted by a complaint intake.
07 Sept 2021Revisit
07 Sept 2021Revisit
Concluded that all deficiencies were corrected and that the site is back in compliance. A follow-up review found no new noncompliance.
30 Aug 2021Revisit
30 Aug 2021Revisit
Investigated a revisit survey for previously cited deficiencies; all deficiencies were corrected and no new noncompliance was found.
30 Aug 2021Revisit
30 Aug 2021Revisit
Verified that prior deficiencies were corrected and no new noncompliance was found.
23 Aug 2021Complaint
23 Aug 2021Complaint
Found no deficiencies identified during the complaint investigation and COVID-19 focused infection control survey.
15 Jul 2021Life Safety
15 Jul 2021Life Safety
Found multiple life-safety deficiencies, including missing delayed-egress signage, hazardous-area enclosure issues, obstructed sprinkler discharge, improper extinguisher height, unsealed penetrations, and inappropriate power strips in patient areas.
NFPA 101 2012, 19.3.5.1; 9.7.5; NFPA 25 2011, 5.2.1.2Sprinkler System - Maintenance and Testing
NFPA 10 2010, 6.1.3.8.1Portable Fire Extinguishers
NFPA 101 2012, 19.3.6.2.3Corridors - Construction of Walls
NFPA 101 2012, 9.1.2; NFPA 99 2012, 10.2.3.6; NFPA 70 2011, 400.8Electrical Equipment - Power Cords and Extension Cords
15 Jul 2021Licensure
15 Jul 2021Licensure
Identified multiple deficiencies in resident rights, care planning, nutrition, infection control, and medication safety with several care processes not meeting regulatory requirements.
Identified deficiencies in dietetic services, including unqualified dietary management, insufficient RD on-site hours, and concerns with sanitation and meal temperatures.
Wyoming Rules and Regulations Chapter 11 Sec. 11(a)(i)Dietetic Services
23 Jun 2021Complaint
23 Jun 2021Complaint
Found that three residents needing bathing assistance did not receive showers as scheduled, with gaps in care and documentation.
CFR 483.24(a)(2)ADL Care Provided for Dependent Residents
16 Apr 2021Complaint
16 Apr 2021Complaint
Found no deficiencies identified in response to a complaint investigation and a COVID-19 focused infection control survey.
12 Apr 2021Revisit
12 Apr 2021Revisit
Concluded all prior deficiencies were corrected and no new noncompliance was found.
04 Mar 2021Complaint
04 Mar 2021Complaint
Investigated complaints identified deficiencies in handling resident personal funds statements and in responding to high blood glucose levels in a resident with diabetes.
§483.10(f)(10)(iii)Accounting and Records of Personal Funds
§483.25Quality of care
16 Feb 2021Revisit
16 Feb 2021Revisit
Found multiple egress doors with delayed-egress locking that required more than the allowed force to release, indicating unsafe egress conditions during emergencies.
Found no deficiencies identified related to the complaint investigations and the COVID-19 focused infection control survey. The surveys were conducted from 12/30/2020 through 1/4/2021.
09 Dec 2020Complaint
09 Dec 2020Complaint
Investigated complaints and infection-control concerns; found multiple deficiencies in wound care, pressure ulcer prevention/healing, catheter care, and infection prevention.
CFR 483.25Quality of care
CFR 483.25(b)(1)(i)(ii)Skin Integrity
CFR 483.25(e)Bowel/Bladder Incontinence
CFR 483.80Infection Prevention & Control
22 Oct 2020Licensure
22 Oct 2020Licensure
Found no deficiencies related to infection control during a COVID-19 focused survey.
22 Oct 2020Licensure
22 Oct 2020Licensure
Found no deficiencies related to infection control during the focused survey.
11 Sept 2020Complaint
11 Sept 2020Complaint
Found no deficiencies identified during complaint and infection control surveys.
02 Sept 2020Revisit
02 Sept 2020Revisit
Determined that the prior deficiencies were back in substantial compliance following a follow-up survey.
02 Sept 2020Revisit
02 Sept 2020Revisit
Determined that previously cited deficiencies were back in substantial compliance after a follow-up survey conducted from 8/26/20 through 9/2/20.
07 May 2020Complaint
07 May 2020Complaint
Found no deficiencies identified during the complaint-based review and infection control assessment.
06 Apr 2020Licensure
06 Apr 2020Licensure
Investigated a COVID-19 focused infection-control survey and found no deficiencies.
16 Mar 2020Licensure
16 Mar 2020Licensure
Investigated complaints found multiple deficiencies across wound care, medications, nutrition, meal timing, food safety, and infection control with several items not meeting requirements.
CFR 483.25Quality of care
CFR 483.45(f)(2)Residents are free of significant medication errors
CFR 483.25(g)(1)-(3)Nutrition/Hydration Status Maintenance
CFR 483.60(f)(1)-(3)Frequency of Meals
CFR 483.60(i)(1)-(2)Food safety requirements
CFR 483.80Infection Prevention & Control
10 Feb 2020Complaint
10 Feb 2020Complaint
Found deficiencies in daily living care and documentation, including inconsistent bathing schedules and incomplete care plans for residents.
Type A—ADL care for dependent residents
Type A—ADL care Provided for Dependent Residents
Type A—ADL care Provided for Dependent Residents
08 Jan 2020Complaint
08 Jan 2020Complaint
Found no deficiencies identified during the complaint investigation.
22 Nov 2019Complaint
22 Nov 2019Complaint
Concluded that no deficiencies were identified during the complaint investigation.
26 Sept 2019Complaint
26 Sept 2019Complaint
Investigated the complaint and found no deficiencies.
24 Sept 2019Revisit
24 Sept 2019Revisit
Found no deficiencies. All prior deficiencies were corrected, and no new noncompliance was identified.
24 Sept 2019Revisit
24 Sept 2019Revisit
Verified compliance after a follow-up visit; all prior deficiencies were corrected and no new noncompliance was found.
16 Sept 2019Revisit
16 Sept 2019Revisit
Verified that previously cited life safety deficiencies were corrected and compliance was restored.
30 Aug 2019Complaint
30 Aug 2019Complaint
Identified a deficiency where an ordered medication was not administered as prescribed, leading to multiple missed doses and potential significant medication error related to a resident's treatment plan.
CFR 483.45(f)(2)Residents are free of significant medication errors
15 Aug 2019Complaint
15 Aug 2019Complaint
Investigated a complaint and found deficiencies in PASARR screening, staffing adequacy, medication oversight, and infection control.
483.20(k)(1)-(3)PASARR Screening for MD & ID
483.35(a)(1)-(2)Sufficient Staffing
483.45(c)Drug Regimen Review
483.80Infection Prevention & Control
15 Aug 2019Licensure
15 Aug 2019Licensure
Found no deficiencies. The licensure survey determined compliance with state requirements.
14 Aug 2019Life Safety
14 Aug 2019Life Safety
Cited deficiencies related to emergency lighting, gas cylinder storage, and combustible decorations.
NFPA 101 Life Safety Code, 2012 editionEmergency Lighting
NFPA 101 Life Safety CodeGas Equipment - Cylinder and Container Storage
NFPA 101 Life Safety Code; NFPA 701; NFPA 289Combustible Decorations
31 Jul 2019Complaint
31 Jul 2019Complaint
Found a lack of system to reconcile controlled drug MARs with narcotics logs, and a discrepancy was not identified or investigated.
CFR 483.45(a)(b)(1)-(3)Pharmacy Services
25 Jul 2019Complaint
25 Jul 2019Complaint
Investigated a complaint about improper pressure sore management, identifying a failure to assess, monitor, and treat wounds, which caused harm to a resident. The deficiency involved lack of wound assessment and treatment documentation.
CFR 483.25(b)(1)(ii)Pressure ulcers
16 Jul 2019Complaint
16 Jul 2019Complaint
Investigated a complaint; found no deficiencies.
09 Jul 2019Complaint
09 Jul 2019Complaint
Investigated a complaint and found no deficiencies.
08 Mar 2019Revisit
08 Mar 2019Revisit
Determined that all prior deficiencies were corrected and no new noncompliance was found.
27 Feb 2019Revisit
27 Feb 2019Revisit
Verified that all previously cited deficiencies were corrected and the site was back in compliance.
31 Jan 2019Life Safety
31 Jan 2019Life Safety
Found life-safety deficiencies: egress doors not maintained per NFPA 101 Life Safety Code and smoking areas not in compliance, with cigarette butt litter observed near a smoking area.
NFPA 101 Life Safety Code (2012 edition)Egress Doors
NFPA 101 Life Safety Code (2012 edition)Smoking Regulations
31 Jan 2019Complaint
31 Jan 2019Complaint
Investigated a recertification survey and found multiple deficiencies across PASARR, care planning, bowel management, incontinence, psychotropic meds, diet and infection control.
483.20(k)(4)Significant Change Notification
483.21(b)(1)Develop/Implement Comprehensive Care Plan
483.25Quality of Care
483.25(e)Incontinence (Bowel/Bladder)
483.45Free from Unnecessary Psychotropic Meds/PRN Use
483.60Qualified Dietary Staff
483.60(e)Therapeutic Diets Prescribed by Physician
483.80Infection Prevention & Control
31 Jan 2019Licensure
31 Jan 2019Licensure
Concluded compliance with state requirements after completing the licensure survey.
06 Dec 2018Complaint
06 Dec 2018Complaint
Investigated a complaint survey and found no deficiencies.
12 Sept 2018Complaint
12 Sept 2018Complaint
Investigated a complaint and found no deficiencies identified.
12 Sept 2018Revisit
12 Sept 2018Revisit
Verified that all previous deficiencies were corrected and no new noncompliance was found.
15 Aug 2018Revisit
15 Aug 2018Revisit
Concluded that all previously cited deficiencies were corrected and no new noncompliance was found. Confirmed compliance with all regulations surveyed.
16 Jul 2018Complaint
16 Jul 2018Complaint
Investigated the facility identified multiple deficiencies including failure to provide timely transfer/discharge notices, issues with medication management and pharmacy services, and gaps in infection control and overall resident care practices.
§483.15(c)(3)Notice before transfer
§483.45(a)Pharmacy Services
§483.80Infection prevention and control
§483.60(i)Food service and sanitation
—Resident Specific
16 Jul 2018Licensure
16 Jul 2018Licensure
Found no deficiencies. The review indicated compliance with state requirements.
10 Jul 2018Life Safety
10 Jul 2018Life Safety
Investigated electrical safety deficiencies; power strips were used in patient care areas without clear UL listing and an oxygen concentrator was plugged into one under a resident's bed.
NFPA 101 Life Safety Code, 2012 edition; NFPA 70Electrical systems – use of power strips and extension cords in patient care areas
26 Jun 2018Revisit
26 Jun 2018Revisit
Determined that all prior deficiencies were corrected and no new deficiencies were found.
04 May 2018Complaint
04 May 2018Complaint
Investigated a complaint about discharge planning and access to health information; found deficiencies in discharge planning and in providing copies of medical records.
§483.21(c)(1) Discharge Planning ProcessDischarge Planning Process
§483.21(c)(1) Discharge Planning ProcessDischarge Planning Process (continued)
23 Mar 2018Complaint
23 Mar 2018Complaint
Investigated a complaint survey conducted from 2018-03-21 to 2018-03-23 and found no deficiencies.
22 Feb 2018Revisit
22 Feb 2018Revisit
Conducted a complaint revisit on 2018-02-22 for prior deficiencies cited on 2017-12-29. Found all deficiencies corrected and no new noncompliance.
19 Jan 2018Complaint
19 Jan 2018Complaint
Investigated the complaint survey and found no deficiencies identified.
29 Dec 2017Complaint
29 Dec 2017Complaint
Investigated a complaint regarding residents' personal belongings not being inventoried; found missing inventories and incomplete documentation of residents' personal effects.
§483.10(e)Respect and Dignity
28 Dec 2017Revisit
28 Dec 2017Revisit
Concluded that all previously cited deficiencies were corrected and no new noncompliance was found.
27 Nov 2017Complaint
27 Nov 2017Complaint
Investigated a discharge notice issue and found that an updated discharge notice was not provided to one resident, with related documentation gaps identified.
§ 483.70(l)Notice requirements before transfer/discharge
18 Oct 2017Complaint
18 Oct 2017Complaint
Investigated a complaint and found no deficiencies.
18 Oct 2017Revisit
18 Oct 2017Revisit
Concluded no deficiencies; prior deficiencies were corrected.
13 Oct 2017Revisit
13 Oct 2017Revisit
Concluded that all previously cited deficiencies were corrected and no new noncompliance was found.
02 Oct 2017Revisit
02 Oct 2017Revisit
Verified prior deficiencies were corrected and no new violations were found.
15 Aug 2017Complaint
15 Aug 2017Complaint
Found multiple deficiencies involving resident rights, privacy, and protection from abuse, with ongoing issues in staff training and policy implementation.
483.12(a)(1)Free from abuse, neglect and exploitation
483.12(b)(1)-(3); 483.95(c)(1)-(3)Policies and procedures addressing abuse, neglect and exploitation; training
483.12(b)(1)-(3); 483.95(c)(1)-(3)Policies and procedures to investigate abuse, neglect, exploitation; staff training
03 Aug 2017Complaint
03 Aug 2017Complaint
Inspectors identified multiple deficiencies in housekeeping and maintenance, social services, medical record documentation, and care planning, with notable safety and environmental concerns and gaps in staff training.
483.10(i)(2)Housekeeping & Maintenance Services
483.10(d)Provision of Medically Related Social Services
—Environmental Conditions
—Laboratory & Medical Records
—Staff Training & Oversight
03 Aug 2017Licensure
03 Aug 2017Licensure
Determined the facility was in compliance with State requirements following a licensure survey conducted from 7/31/17 to 8/3/17.
01 Aug 2017Life Safety
01 Aug 2017Life Safety
Investigated a complaint and found several life-safety deficiencies, including blocked means of egress, a locked exit door, sprinkler system maintenance issues, improper corridor storage, and limited oxygen storage.
2012 NFPA 101 Life Safety Code (Sections related to egress)Corridor obstructed and inadequate means of egress
2012 NFPA 101 Life Safety Code (Sections on egress and doors)Exit door locked/opening restrictions
2012 NFPA 101 Life Safety Code (Sprinkler/egress requirements)Sprinkler system and egress-related findings
2012 NFPA 101 Life Safety Code (Storage and access requirements)Improper storage in corridors
Concluded that compliance was restored as of June 12, 2017 after deficiencies identified during a complaint investigation were addressed.
15 Jun 2017Complaint
15 Jun 2017Complaint
Investigated a complaint; found no deficiencies identified.
11 May 2017Complaint
11 May 2017Complaint
Identified a pattern of falls with safety concerns related to health decline; care plan details and safety measures were documented to address the issue.
—Risk for falls
14 Apr 2017Complaint
14 Apr 2017Complaint
The investigation identified deficiencies related to resident privacy, discharge planning, and dignity in care and treatment.
—Confidentiality/Privacy of Resident Health Information
—Discharge Planning
—Dignity and Respect of Individuality
14 Apr 2017Revisit
14 Apr 2017Revisit
Concluded that the earlier deficiencies were corrected and compliance was restored after a revisit survey.
29 Dec 2016Complaint
29 Dec 2016Complaint
Investigated a complaint survey conducted in late December 2016; found no deficiencies.
05 Dec 2016Revisit
05 Dec 2016Revisit
Investigated a complaint and cited a deficiency under regulatory requirement 483.15(h)(2).
483.15(h)(2)Regulatory deficiency 483.15(h)(2)
05 Dec 2016Complaint
05 Dec 2016Complaint
Investigated a complaint; no deficiencies were identified.
28 Oct 2016Revisit
28 Oct 2016Revisit
Found no deficiencies.
27 Oct 2016Revisit
27 Oct 2016Revisit
Identified multiple sanitation deficiencies in kitchen areas and related surfaces with dirty equipment and surfaces observed during the visit.
483.15(h)(2)Housekeeping and Maintenance Services
27 Oct 2016Revisit
27 Oct 2016Revisit
Identified deficiencies tied to federal regulations with multiple corrections completed.
483.10(b)(11)
483.10(f)(1)
483.12(a)(4)-(6)
483.15(a)
483.15(e)(1)
483.20(b)(1)
483.25(f)
483.25(m)(1)
483.30(e)
27 Oct 2016Revisit
27 Oct 2016Revisit
Found deficiencies in housekeeping/maintenance and kitchen sanitation during a follow-up visit.
483.15(h)(2)Housekeeping and Maintenance Services
—Kitchen sanitation and monitoring
483.75(i)(1)Food procurement, storage, preparation and serving - Sanitary conditions
483.75(o)(1)Provider's plan of correction monitoring
27 Oct 2016Revisit
27 Oct 2016Revisit
Verified that deficiencies reported previously were corrected during the follow-up review.
14 Sept 2016Complaint
14 Sept 2016Complaint
Investigated a resident’s inability to swallow medications and a delayed hospital transport after stroke symptoms, with documentation showing failures in timely medical response.
—Continued From page 3 – resident could not swallow medications and delayed hospital transport
31 Aug 2016Complaint
31 Aug 2016Complaint
Found deficiencies in wound care and skin integrity, including a pressure injury that was not adequately monitored or documented.
—Continued From page 1 - Wound care / skin integrity
14 Jul 2016Complaint
14 Jul 2016Complaint
Investigated reported concerns about resident care and management; identified several deficiencies related to resident rights, transfers/discharges, dignity, needs assessment, and care planning.
—Right to Voice Grievances without Reprisal
—Notice Requirements Before Transfer/Discharge
—Dignity and Respect for Individuality
—Identification of Needs-Residents Requiring Accommodations
Investigated a complaint and concluded no deficiencies; the survey found compliance with state requirements.
13 Jul 2016Life Safety
13 Jul 2016Life Safety
Identified life-safety deficiencies and missing documentation related to smoke barriers and related door hardware. Noted multiple observations and follow-up items requiring correction.
NFPA 101 Life Safety Code StandardSelf-closing doors to resist smoke passage
13 May 2016Complaint
13 May 2016Complaint
Found no deficiencies identified during the complaint investigation.
28 Mar 2016Complaint
28 Mar 2016Complaint
Investigated the complaint and found no deficiencies.
10 Dec 2015Revisit
10 Dec 2015Revisit
Identified multiple deficiencies tied to federal requirements; several corrections were completed by 10/19/2015.
483.10(b)(11)
483.60(b)(d)(e)
483.75(f)
483.75(o)(1)
483.25(c)
483.15(h)(1)
483.40(a)
483.25(k)
483.35(u)
483.25(k)
10 Dec 2015Complaint
10 Dec 2015Complaint
Found no deficiencies identified during a complaint survey conducted in December 2015.
28 Oct 2015Revisit
28 Oct 2015Revisit
Investigated the complaint and found no deficiencies.
28 Oct 2015Revisit
28 Oct 2015Revisit
Observed that corrections were completed for identified deficiencies.
11 Sept 2015Complaint
11 Sept 2015Complaint
Found deficiencies in resident care and administrative processes, with gaps in grievance handling, documentation, and care planning.
—Grievances follow-up and investigation
08 Sept 2015Life Safety
08 Sept 2015Life Safety
Investigated a complaint and found deficiencies related to maintenance of mechanical systems and improper storage in the boiler room.
42 CFR 483.70(a)Life Safety Code
2006 IMC Section 315.2.3IMC Life Safety - International Mechanical Code
08 Sept 2015Life Safety
08 Sept 2015Life Safety
Investigated a complaint regarding safety and electrical practices; identified noncompliance with NFPA 99 for medical gas storage and improper use of extension cords in a patient area.
NFPA 99Protection of medical gas storage and administration areas
NFPA 70Electrical wiring and extension cords in patient care areas
20 Aug 2015Revisit
20 Aug 2015Revisit
Investigated deficiencies in life safety and NFPA 101 standards; corrections were completed prior to the follow-up visit.
NFPA 101 / Life Safety CodeNFPA 101 / Life Safety Code deficiency
NFPA 101 / Life Safety CodeNFPA 101 / Life Safety Code deficiency
NFPA 101 / Life Safety CodeNFPA 101 / Life Safety Code deficiency
NFPA 101 / Life Safety CodeNFPA 101 / Life Safety Code deficiency
NFPA 101 / Life Safety CodeNFPA 101 / Life Safety Code deficiency
NFPA 101 / Life Safety CodeNFPA 101 / Life Safety Code deficiency
20 Aug 2015Revisit
20 Aug 2015Revisit
Identified life safety code deficiencies and confirmed corrections completed.
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
20 Aug 2015Revisit
20 Aug 2015Revisit
Investigated prior deficiencies; corrections completed for identified items. Follow-up confirmed corrective actions were completed.
20 Aug 2015Revisit
20 Aug 2015Revisit
Verified prior corrections were completed; no deficiencies were found.
14 Aug 2015Revisit
14 Aug 2015Revisit
Identified multiple deficiencies with regulatory citations; corrections completed.
Type A483.10(e); 483.75(l)(4)
Type A483.12(a)(4)-(6)
Type A483.13(c)(11)(i)-(iii)
Type A483.15(a)
Type A483.35(e)
Type A483.35(i)
Type A483.40(b)
Type A483.75(i)(2)(iv)
Type A483.75(k)(1)
Type A483.75(k)(2)
14 Aug 2015Revisit
14 Aug 2015Revisit
Verified corrections were completed for prior deficiencies. The follow-up indicated corrections were completed.
14 Aug 2015Complaint
14 Aug 2015Complaint
Found no deficiencies identified after a complaint survey conducted from 08/13/2015 through 08/14/2015.
18 Jun 2015Complaint
18 Jun 2015Complaint
An investigation found deficiencies in notifying residents before transfers/discharges and in protecting residents' privacy and records. The findings identified several related issues and required corrective actions.
483.12(a)(4)-(6)Notice Requirements Before Transfer/Discharge
483.10(b)(4)Personal Privacy/Confidentiality of Records
18 Jun 2015Licensure
18 Jun 2015Licensure
Concluded the site was in compliance with state requirements after a survey conducted 2015-06-15 to 2015-06-18.
15 Jun 2015Life Safety
15 Jun 2015Life Safety
Found life-safety deficiencies including inadequate separation for oxygen storage and issues related to eye wash station compliance and facility maintenance.
—Oxygen storage separation deficiency
—IPC Life Safety / Plumbing Code – eye wash stations
—State Life Safety – Paint/maintenance
15 Jun 2015Life Safety
15 Jun 2015Life Safety
Found multiple life-safety deficiencies including issues with corridor doors, fire ratings, sprinkler access, and generator/oxygen transfer procedures, with corrective actions planned.
—Corridor Doors
NFPA 101 Life Safety Code; Sections 19.3.2.1 and 7.9.3Fire Ratings
—Sprinkler Systems
—Generator
—Oxygen Transfer
28 May 2015Revisit
28 May 2015Revisit
Investigated prior deficiencies and verified corrections; follow-up completed.
483.15(a)
483.25(a)(3)
19 Mar 2015Complaint
19 Mar 2015Complaint
Identified deficiencies in providing necessary daily living care, with residents wearing soiled clothing and dirty lap belts due to inadequate staff assistance with bathing, dressing, and hygiene.
483.26(a)(3)ADL CARE PROVIDED FOR DEPENDENT RESIDENTS
—LAP BELT MAINTENANCE
26 Feb 2015Revisit
26 Feb 2015Revisit
Identified deficiencies related to federal requirements; corrections completed.
483.25(a)(3)
483.25(h)
483.30(a)
02 Jan 2015Complaint
02 Jan 2015Complaint
Investigated the complaint and found deficiencies related to resident safety, fall prevention, and monitoring. Noted gaps in care planning and ongoing quality oversight.
—Continued From page 2
—Continued From page 9/10/15
—Continued From page 16
—Continued From page 8
10 Dec 2014Revisit
10 Dec 2014Revisit
Cited deficiencies in resident rights and quality of care; corrective actions completed.
483.10(e)(2)-(5)Resident rights
483.25(h)Quality of care
13 Nov 2014Complaint
13 Nov 2014Complaint
Investigated a complaint and found no deficiencies.
23 Oct 2014Complaint
23 Oct 2014Complaint
Found deficiencies in handling residents' personal funds and in documenting out-of-facility releases.
Section 1611(a)(3)(B) of the ActResident funds – deposit and accounting
—Out-of-facility releases and related documentation
22 Aug 2014Complaint
22 Aug 2014Complaint
Investigated care provided to residents and found deficiencies in medical symptom management, restraint-related practices, and wound care.
—INITIAL COMMENTS
—RESTRAINTS/RESTRAINT-RELATED CARE
—NURSING CARE/DEFICIENCIES RELATING TO SKIN INTEGRITY
—TREATMENT/PRESSURE ULCERS
29 Apr 2014Revisit
29 Apr 2014Revisit
Concluded no deficiencies were identified during the follow-up visit.
20 Mar 2014Life Safety
20 Mar 2014Life Safety
Identified life-safety deficiencies related to smoke barriers and corridor doors, with corrective actions required and a near-term compliance date.
NFPA 101 Life Safety Code StandardCorridor protection and smoke barrier deficiencies
20 Mar 2014Revisit
20 Mar 2014Revisit
Investigated and found that alleged abuse/neglect incidents were not reported promptly to the administrator and the State Survey Agency within the required timeframe.
—Reporting and documenting incidents
20 Mar 2014Revisit
20 Mar 2014Revisit
Investigated incidents and found deficiencies in reviewing and reporting incidents to the State Survey Agency.
—Review and reporting of incidents to the State Survey Agency
20 Mar 2014Complaint
20 Mar 2014Complaint
Identified deficiencies in resident care planning and monitoring, with required corrective actions and ongoing oversight.
20 Mar 2014Licensure
20 Mar 2014Licensure
Determined compliance with state requirements after a recertification survey conducted March 17-20, 2014.
17 Jan 2014Complaint
17 Jan 2014Complaint
Identified deficiencies for failing to report abuse allegations to the state survey agency and inadequate investigations.
Type A—Failure to report alleged abuse to state survey agency
Type B—Inadequate investigation and policy regarding abuse and neglect
03 Jan 2014Complaint
03 Jan 2014Complaint
Found no deficiencies related to the complaint investigation.
24 Oct 2013Revisit
24 Oct 2013Revisit
Found no deficiencies.
15 Aug 2013Complaint
15 Aug 2013Complaint
Investigation identified deficiencies in maintaining resident dignity, ensuring care services are provided by qualified staff, and adequacy of nutrition-related processes, with multiple systemic actions required.
483.16(a)Dignity and Respect of Individuality
—Provision of Services by Qualified Staff
—Nutritional and Hydration Services/Orders
—Staff Training/Professional Standards
28 Mar 2013Complaint
28 Mar 2013Complaint
Investigated a complaint and found no deficiencies identified.
31 Jan 2013Complaint
31 Jan 2013Complaint
Investigators identified deficiencies related to privacy of resident records and failure to complete and document comprehensive assessments.
Type A483.10(e), 483.75(i)(4)Personal Privacy/Confidentiality of Records
Type A483.20(b)(1)Comprehensive Assessments
31 Jan 2013Revisit
31 Jan 2013Revisit
Investigated a resident privacy concern, found mail delivery delays, and identified deficiencies in safeguarding resident records.
—Privacy and confidentiality of resident records
—Timely delivery of mail to residents
—Admissions/Resident records documentation
31 Jan 2013Licensure
31 Jan 2013Licensure
Investigated the licensure survey and found no deficiencies identified.
30 Jan 2013Life Safety
30 Jan 2013Life Safety
Identified multiple life-safety deficiencies related to smoke barriers, penetrations, and ongoing monitoring of safety systems; require corrective actions and follow-up.
NFPA 101 Life Safety Code StandardLife Safety Code Standard
Investigated deficiencies related to skin integrity and care planning; weekly skin checks were not consistently performed and documentation did not reflect changes in residents' skin conditions.
—Skin integrity monitoring
—Care planning for pressure ulcers and related condition changes
09 Aug 2012Revisit
09 Aug 2012Revisit
Found multiple life-safety deficiencies cited. Corrective actions were completed by the dates listed.
483.15(a)
483.15(g)(1)
483.20(d)(3), 483.10(k)(2)
483.25(a)(3)
07 Jun 2012Complaint
07 Jun 2012Complaint
Identified deficiencies in social services and daily care planning, with inadequate social-work interventions and incomplete activities of daily living (ADL) support for a resident.
Type A42 CFR 483.15(a)(3) DIGNITY AND RESPECT OF INDIVIDUALITYDIGNITY AND RESPECT OF INDIVIDUALITY
Type A42 CFR 483.20(d)(3) PROVISION OF MEDICALLY-RELATED SOCIAL SERVICEProvision of medically-related social service
Type A42 CFR 483.25(a)(3) ADL CARE PROVIDED FOR SS=D DEPENDENT RESIDENTSADL CARE PROVIDED FOR DEPENDENT RESIDENTS
21 May 2012Revisit
21 May 2012Revisit
Found deficiencies cited and corrections completed during the follow-up visit.
483.15(g)(1)
483.25(a)(2)
483.55(a)
14 Mar 2012Complaint
14 Mar 2012Complaint
Investigated deficiencies in resident care and coordination of dental services, including a delayed dental intervention and inadequate restorative planning.
—Restorative program and denture/dental care
—Follow-up and monitoring of dental care/restorative program
08 Mar 2012Revisit
08 Mar 2012Revisit
Investigated uncorrected deficiencies and confirmed corrections were completed.
483.15(a)
483.20(d), 483.20(k)(1)
483.25
08 Mar 2012Revisit
08 Mar 2012Revisit
Verified corrections completed for deficiencies noted during a follow-up evaluation.
483.13(c)(1)(ii)-(iii), (c)(2)-(4)
483.15(a)
483.20(b)(2)(ii)
483.20(g)-(i)
483.20(d)(3), 483.10(k)(2)
483.20(k)(3)(i)
483.75(e)(5)-(7)
483.70(g)
483.70(h)(2)
483.75(i)(1)
01 Mar 2012Revisit
01 Mar 2012Revisit
Identified life safety code deficiencies and corrections were completed and verified on follow-up.
NFPA 101Life Safety Code
NFPA 101Life Safety Code
NFPA 101Life Safety Code
NFPA 101Life Safety Code
NFPA 101Life Safety Code
20 Jan 2012Licensure
20 Jan 2012Licensure
Found no deficiencies identified during the state licensure survey conducted on January 6, 2012.
20 Jan 2012Licensure
20 Jan 2012Licensure
An investigation identified deficiencies in resident care and facility processes, necessitating corrective actions.
19 Jan 2012Life Safety
19 Jan 2012Life Safety
Found life-safety and maintenance deficiencies during the evaluation, including door hardware/smoke-door performance, sprinkler system maintenance, and safety-signage issues.
NFPA 101 Life Safety Code Standard 19.3.2.1Corridor doors/smoke-resistance
NFPA 101 Life Safety Code StandardMonitoring/maintenance of life-safety systems
NFPA 101 Life Safety Code StandardFire protection systems maintenance/installation
NFPA 101 Life Safety Code StandardFire drills and safety procedures
NFPA 101 Life Safety Code StandardCorrective actions for sprinkler head failures
NFPA 101 Life Safety Code StandardContinued from page 9 – signage/requirements
NFPA 101 Life Safety Code StandardInterior furnishings and drapery safety standards
06 Jan 2012Complaint
06 Jan 2012Complaint
Found deficiencies related to resident dignity and respect, and failures to develop and implement comprehensive care plans and hydration-related care.
483.15(a)Dignity and respect of individuality
483.20Develop Comprehensive Care Plans
483.25Provide care/services for highest well-being
30 Sept 2011Complaint
30 Sept 2011Complaint
Found no deficiencies identified in the complaint investigation.
16 Jun 2011Complaint
16 Jun 2011Complaint
Found no deficiencies identified during the complaint investigation.
25 Feb 2011Licensure
25 Feb 2011Licensure
Investigated a deficiency in dietetic services; the required supervisor qualifications and related training were not met.
Wyoming Department of Health Aging Division Rules and Regulations for Program Administration of Nursing Care Facilities Chapter 11Dietetic Services (Section 11)
25 Feb 2011Licensure
25 Feb 2011Licensure
Investigated a deficiency in dietary services; the supervisor did not meet the required qualifications.
Type AWyoming Rules and Regulations for Nursing Homes, Chapter 11, Dietary ServicesSection 11: Dietary Services – supervisor qualifications
25 Feb 2011Complaint
25 Feb 2011Complaint
Investigated a complaint and identified multiple deficiencies in resident care, documentation, and safety-related processes.
483.15(e)(1)REASONABLE ACCOMMODATION OF NEEDS/PREFERENCES
22 Feb 2011Life Safety
22 Feb 2011Life Safety
Identified deficiencies in fire drill execution and staff response to simulated emergencies, including failure to announce Code Red and improper door/alarm actions.
NFPA 101 Life Safety Code StandardFire drill procedures and Code Red response
25 Jan 2011Life Safety
25 Jan 2011Life Safety
Identified several life-safety deficiencies during the survey, including blocked corridors, delayed egress locks, damaged sprinkler components, missing electrical faceplates, and inconsistent fire drills.
NFPA 101 LIFE SAFETY CODE STANDARDContinued From page 2
NFPA 101 LIFE SAFETY CODE STANDARDDelayed Egress Locks
NFPA 101 LIFE SAFETY CODE STANDARDContinued From page 4
NFPA 101 LIFE SAFETY CODE STANDARDContinued From page 5
NFPA 101 LIFE SAFETY CODE STANDARD; NFPA 13; NFPA 25; 9.7.5Continued From page 3
29 Dec 2010Revisit
29 Dec 2010Revisit
Investigated corrections for previously cited deficiencies; follow-up showed substantial compliance.
483.20(b)(2)(ii) Life Safety CodeLife Safety Code deficiency
28 Oct 2010Complaint
28 Oct 2010Complaint
Investigated deficient practice found that two residents did not receive a comprehensive assessment after a fall and related events.
—COMPREHENSIVE ASSESSMENTS
10 Sept 2010Revisit
10 Sept 2010Revisit
Verified that corrections from the prior survey were completed; no deficiencies were identified during the revisit.
10 Sept 2010Revisit
10 Sept 2010Revisit
Found no deficiencies during the follow-up visit conducted on 2010-09-10 after the prior survey.
20 Jul 2010Complaint
20 Jul 2010Complaint
Identified inadequate hydration due to insufficient fluid intake for residents. A hydration-related deficiency was cited.
—Hydration
08 Jul 2010Complaint
08 Jul 2010Complaint
The facility was found to have several deficiencies in resident safety, medical monitoring, pain management, and documentation, including self-harm risk, vital-sign monitoring, dental and clinical records, and ongoing oversight of care plans.
—Self-harm risk assessment and documentation
—Vital signs and monitoring not performed as ordered
—Pain management documentation inadequate
—Restorative services documentation and monitoring
—Laboratory results in medical records
—Systematic changes for pain management documentation
02 Apr 2010Revisit
02 Apr 2010Revisit
Identified deficiencies cited against the provider for several CMS conditions of participation during a follow-up visit, with multiple items noted as not in compliance and some corrections documented.
483.70(h)
483.75(i)(x1)
483.20(d)(3); 483.10(k)(2)
483.25(a)(2)
483.60(a)
483.25(c)
483.25(h)
23 Mar 2010Revisit
23 Mar 2010Revisit
Identified life-safety deficiencies with corrections completed afterward.
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
28 Jan 2010Complaint
28 Jan 2010Complaint
Investigated an allegation of abuse and found failures in investigating reports, maintaining resident dignity, and ongoing care practices.
Type A483.13(c)(1)(i)(ii), (c)(2)-(4)TREATMENT OF RESIDENTS
Type A483.75(a)Dignity of residents
Type A483.75(b)Observation of care and treatment
Type A483.25Continued from page 15: adequacy of care planning
28 Jan 2010Licensure
28 Jan 2010Licensure
Investigated a licensure survey and found no deficiencies.
30 Dec 2009Revisit
30 Dec 2009Revisit
Identified that all previously cited deficiencies were corrected.
06 Nov 2009Complaint
06 Nov 2009Complaint
The inspection found deficiencies in quality of care, medication administration, and medical-record documentation, including inadequate wound care documentation and medication-record-keeping issues.
483.25Quality of Care
483.25(m)(1)Medication Errors
—Clinical Records
06 Nov 2009Revisit
06 Nov 2009Revisit
Verified corrections completed after a follow-up visit.
26 Aug 2009Complaint
26 Aug 2009Complaint
Found a deficiency in discharge planning; the post-discharge plan of care did not address all needed services for one resident.
Type A483.20(I)(3)Discharge Summary
13 Mar 2009Revisit
13 Mar 2009Revisit
Found deficiencies cited during a post-certification revisit.
483.10(b)(11)
483.13(a)
483.20
483.25(c)
483.60(c)
483.20(k)(3)(i)
483.20(g)
13 Mar 2009Complaint
13 Mar 2009Complaint
Investigated a complaint; found no deficiencies.
12 Mar 2009Revisit
12 Mar 2009Revisit
Investigated a complaint and verified that previously identified deficiencies were corrected.
23 Jan 2009Complaint
23 Jan 2009Complaint
Investigated a resident-care incident and found that relevant parties were not promptly notified when injuries and condition changes occurred.
483.10(b)(11)NOTIFICATION OF CHANGES
20 Jan 2009Life Safety
20 Jan 2009Life Safety
Investigated life-safety concerns and found deficiencies related to separating hazardous areas from resident use and to sprinkler heads. Noted repairs were needed and some penetrations were unsealed.
DNFPA 101 Life Safety Code Standard; 42 CFR 483.70Life Safety Code – separation of hazardous areas
BNFPA 101 Life Safety Code Standard; 42 CFR 483.70Sprinkler systems—obstruction/corrosion
12 May 2006Revisit
12 May 2006Revisit
Concluded that several deficiencies were corrected; however, some remained uncorrected.
483.10(b)(11)
483.10(n)
483.13(c)(1)(i)(ii)-(iii)
483.25(a)(2)
483.20(b)(2)(i)
483.25(a)(2)
483.15(b)(1)
17 Apr 2006Revisit
17 Apr 2006Revisit
Investigated corrections from a prior survey and documented progress toward compliance.
24 Feb 2006Licensure
24 Feb 2006Licensure
Investigations identified deficiencies related to timely notification of residents and families, oversight of medication self-administration, handling of resident funds, and gaps in daily living, social services, and related care planning.
483.10(n)SELF ADMINISTRATION OF DRUGS
—RESIDENT FUNDS/MISAPPROPRIATION
483.25(a)(2)ACTIVITIES OF DAILY LIVING
483.25(b)VISION AND HEARING
483.15(g)(1)SOCIAL SERVICES
23 Feb 2006Life Safety
23 Feb 2006Life Safety
Identified deficiencies included excess trash receptacles in non-hazardous areas and insufficient electrical outlets.
NFPA 101 19.7.5.5Limit number of trash receptacles in non-hazardous areas
NFPA 70; NEC 9.1.2Electrical wiring and equipment in accordance with NFPA 70
18 Mar 2005Revisit
18 Mar 2005Revisit
Verified corrections completed after the follow-up survey and found substantial compliance.
10 Mar 2005Revisit
10 Mar 2005Revisit
Verified corrections completed for previously cited deficiencies and follow-up confirmed compliance.
483.20(h)(5)Life Safety Code deficiency
483.25(h)Life Safety Code deficiency
483.25(c)Life Safety Code deficiency
483.25(d)(2)Life Safety Code deficiency
483.25(d)(1)Life Safety Code deficiency
483.70(h)Life Safety Code deficiency
25 Jan 2005Life Safety
25 Jan 2005Life Safety
Investigated deficiencies in life-safety and fire-protection, finding smoke barrier doors not closing to form a smoke-resisting closure, improper storage of combustibles, and inadequate emergency lighting and maintenance practices.
NFPA 101 LIFE SAFETY CODE STANDARDSmoke barrier doors not closing to form a smoke-resisting barrier
NFPA 101 LIFE SAFETY CODE STANDARDStorage of combustibles (magazines and cardboard boxes) near the Director of Nurses Office
NFPA 101 LIFE SAFETY CODE STANDARDTesting and maintenance of water-based fire protection systems
NFPA 101 LIFE SAFETY CODE STANDARDEmergency lighting near the generator
08 Jan 2005Licensure
08 Jan 2005Licensure
Found deficiencies in residents' vision care, quality of life, and the living environment. The issues included missing glasses for a resident, inadequate provision of dignity-promoting care, and unsafe sanitation in the facility environment.
483.15(a)QUALITY OF LIFE
483.25(b)QUALITY OF CARE
483.70(h)PHYSICAL ENVIRONMENT
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