Gaps in daily therapy and rehabilitation availability
Variable leadership and oversight continuity
Occasional lapses in clinical-care continuity and safety protocols
Summary of reviews
Overall assessment: The facility elicits strongly polarized impressions. Many accounts highlight a high level of clinical skill and an attentive, person-centered approach—particularly from nursing and therapy teams—paired with an organized, welcoming environment and proactive communication with families. These strengths are repeatedly connected to strong teamwork, a smooth admission process, and visible administrative efforts to improve operations. At the same time, a minority of accounts describe serious operational lapses that have materially affected individual residents, producing a mixed reputation that prospective families should weigh carefully.
Care and clinical services: Positive feedback emphasizes competent nursing and rehabilitation services, with multiple mentions of therapy-focused, person-centered plans and good coordination between nursing and therapy staff. Conversely, several accounts point to gaps in therapy frequency and rehabilitation availability for some residents, and a few raised safety-related concerns about resident handling and clinical continuity. One reviewer described an allegation of handling-related injury; additional comments referenced concern following a resident's decline. These items suggest uneven execution of transfer-safety procedures and inconsistency in delivering scheduled rehabilitative services.
Staff and management: Many reviewers praised frontline staff as kind, respectful, and dedicated, and noted strong teamwork and responsive communication from management. Several comments credit recent administrative improvements and an engaged administrator working to address issues. However, other statements indicate variability in staff training, occasional unprofessional conduct, and inconsistency in leadership or oversight across shifts. This pattern suggests that while leadership initiatives are producing positive change, staffing stability and uniform training remain areas for continued focus.
Facilities, housekeeping, dining, and activities: The facility receives frequent praise for its clean, welcoming common areas and organized environment. At the same time, there are specific sanitation concerns raised about resident rooms, bedding, and laundry processes, indicating inconsistent housekeeping performance. Reviews contain limited detail about dining and general activities; where activities are noted, the emphasis is more on therapeutic programming than on recreational offerings. Prospective families should verify current housekeeping protocols and activity schedules during a visit.
Communication and responsiveness: A common strength is open communication and willingness to address concerns promptly—many families described clear, regular updates and collaborative problem-solving with staff. Those positive experiences coexist with accounts where responses were slower or where family concerns highlighted deeper operational issues. As such, communication appears to be a relative strength overall but not uniformly experienced by every family.
Notable patterns and recommendation guidance: The overall pattern is one of generally high-quality, engaged care offset by variability in operational consistency. For many residents the facility appears to deliver strong, coordinated nursing and therapy services in a clean, welcoming setting. However, prospective residents and families should assess current staffing levels, review transfer-safety procedures, confirm the availability and frequency of therapy services, and inquire about housekeeping and laundry quality control during an in-person visit. Those steps can help identify whether the facility’s strengths are consistently applied to a specific room, unit, or shift.
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Location
Douglas Care Center is located at 1108 Birch St, Douglas, WY, 82633.
About Douglas Care Center
Douglas Care Center in Douglas, Wyoming, sits beside the North Platte River where Interstate 25 meets Highway 59, and you know, this place is about providing many kinds of care, because they offer services like independent living, assisted living, memory care for seniors with Alzheimer's and dementia, skilled nursing for those needing help every day, even short-term rehabilitation after surgery or illness, and then there's home health, adult care home options, and hospice care for comfort at the end of life all under one roof, and with their team, which has a lot of experience, they set up programs that encourage folks to make friends and stay active, and there are daily activities for the mind and body, so nobody feels left out. The building itself is 29,454 square feet and has a scenic view because it's surrounded by historic sites, plus you'll find a mix of private and semi-private rooms for different needs-34 private rooms, four semi-private, and a bariatric suite with its own shower, and for bathing there's both a whirlpool tub and a shower room, and every room has a 32-inch flatscreen TV, with laundry service and new technology helping to keep things running smoothly. Douglas Care Center keeps 60 beds for long-term living and gives 20 of those to residents with Alzheimer's or memory concerns, and along with a safe place, they do brain-boosting activities and personal care, and medical supervision is always going on. There's a big dining and activities area where folks can gather to eat and join in different programs. For those who like pets, the center allows them, and when it comes to living arrangements, apartments come in one to four-bedroom sizes, and there are things like washers and dryers, air conditioning, pools, patios, and more, with some places having fitness centers, but there's no listed details about parking or some outside things. They've got policies to protect people of all backgrounds and provide rentals like townhomes and condos if you want. Utilities are covered in the rent, though exactly which ones isn't clear, and garage and entry details aren't written out. The atmosphere is warm, the staff works on making the place feel like home, and meaningful social events are part of each day, so folks get the support and medical help they need, along with some happiness and friendship in their lives. Douglas Care Center's been around since 2008 as part of Douglas Care Center LLC, always aiming to care for even the most frail people who need daily nursing, and everything centers on making sure residents stay as comfortable, healthy, and engaged as possible.
People often ask...
Douglas Care Center offers assisted living, memory care, and skilled nursing.
There are 14 photos of Douglas Care Center on Mirador.
The full address for this community is 1108 Birch St, Douglas, WY 82633.
No, Douglas 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-194
Status
Open
Facility type
Nursing Home
Inspection Reports
152
Reports
28
Type A Citations
0
Type B Citations
55
Complaints
21
Years
24 Sept 2026Revisit
24 Sept 2026Revisit
Verified compliance after a Life Safety Code revisit; all prior deficiencies were corrected and no new noncompliance was found.
01 Sept 2026Revisit
01 Sept 2026Revisit
Found the kitchen extinguishing system not inspected as required by NFPA standards.
2012 NFPA 101; 2011 NFPA 96Cooking Facilities
29 Jul 2026Revisit
29 Jul 2026Revisit
Verified that prior deficiencies were corrected and no new noncompliance was found.
18 Jun 2026Licensure
18 Jun 2026Licensure
Found hot water temperatures at hand washing sinks exceeded the allowed maximum of 110 degrees Fahrenheit in several rooms.
CFR(s): Ch 11 Sec 6 (a)(iv)Physical Environment - Water temperature
18 Jun 2026Complaint
18 Jun 2026Complaint
Identified multiple deficiencies across dietary staffing, food safety, nutrition, dementia care, medication storage, and meal customization.
Inspections identified multiple life-safety deficiencies related to maintenance of systems, emergency lighting, means of egress, egress doors, and cooking facilities.
NFPA 101 Life Safety CodeLife safety code maintenance
NFPA 101 Life Safety CodeEmergency lighting
NFPA 101 Life Safety CodeMeans of Egress - General
NFPA 101 Life Safety CodeEgress doors
NFPA 101 Life Safety Code; NFPA 96Cooking facilities
30 Apr 2026Complaint
30 Apr 2026Complaint
Found that a dependent resident did not receive timely ADL care, with delays in incontinence care and a soiled result.
CFR 483.24(a)(2)ADL Care Provided for Dependent Residents
06 Nov 2025Complaint
06 Nov 2025Complaint
Investigated the complaint; found no deficiencies.
06 Nov 2025Revisit
06 Nov 2025Revisit
Found no deficiencies after a follow-up visit and confirmed prior issues were corrected. Compliance with all regulations surveyed was verified.
17 Sept 2025Complaint
17 Sept 2025Complaint
Investigated a complaint about abuse by a resident and found two residents harmed; also found inadequate grooming and hygiene care for another resident.
483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
483.24(a)(2)ADL Care Provided for Dependent Residents
20 Feb 2025Revisit
20 Feb 2025Revisit
Verified that all previously identified deficiencies were corrected and no new noncompliance was found.
03 Jan 2025Complaint
03 Jan 2025Complaint
Investigated a complaint alleging mismanagement of residents' funds, resident-to-resident abuse, and late reporting of alleged violations; identified deficiencies in funds management, abuse protection, and reporting.
42 CFR 483.10(f)(10)Protection/Management of Personal Funds
42 CFR 483.12(a)(1)Free from Abuse and Neglect
42 CFR 483.12(c)Reporting of Alleged Violations
02 Jan 2025Revisit
02 Jan 2025Revisit
Verified all previous deficiencies were corrected and no new noncompliance was found.
20 Dec 2024Revisit
20 Dec 2024Revisit
Verified no deficiencies or new non-compliance. Compliance achieved.
15 Nov 2024Complaint
15 Nov 2024Complaint
Investigated a recertification survey identified multiple deficiencies across discharge planning, safety, staffing, behavioral health, social services, dietary management, and infection control.
§483.21(c)(2)(i)-(iv)Discharge Summary
§483.25(n)(1)-(4)Bed Rails
§483.35(a)(1)-(2)Sufficient Staff
§483.40Behavioral Health Services
§483.40(b)(3)Treatment/Service for Dementia
§483.40(d)Provision of Medically Related Social Service
§483.60(a)(1)-(2)Qualified Dietary Staff
§483.80(a)-(f)Infection Prevention & Control
14 Nov 2024Life Safety
14 Nov 2024Life Safety
Identified multiple life-safety deficiencies, including doors without proper self-closing, dislodged sprinkler escutcheons, obstructed extinguishers, untested dampers, and no documented plan for inspecting main/feeder breakers.
NFPA 101; 18.2.2.2.7, 7.2.1.8.2Doors with Self-Closing Devices
NFPA 101, Sec. 19.3.5.1; 9.7; NFPA 13, Sec. 6.2.7.1Sprinkler System - Installation
NFPA 101, Sec. 19.3.5.12 and 9.7.4.1; 2010 NFPA 10, Sec. 1.6.6Portable Fire Extinguishers
NFPA 99 Ch.10 Sec. 4.4.1.2; NFPA 90A; NFPA 111; NFPA 70Electrical Systems - Essential Electric System
03 Apr 2024Complaint
03 Apr 2024Complaint
Found no deficiencies identified in the complaint investigation.
20 Dec 2023Complaint
20 Dec 2023Complaint
Found no deficiencies. The investigation concluded that no deficiencies were identified pertaining to the complaint.
01 Nov 2023Revisit
01 Nov 2023Revisit
Concluded that all prior deficiencies were corrected and back in compliance.
01 Nov 2023Revisit
01 Nov 2023Revisit
Verified that prior deficiencies were corrected and no new noncompliance was found.
27 Oct 2023Revisit
27 Oct 2023Revisit
Verified compliance after follow-up and confirmed that earlier deficiencies were corrected with no new noncompliance identified.
27 Oct 2023Revisit
27 Oct 2023Revisit
Verified that previously identified deficiencies were corrected and no new noncompliance was found.
30 Aug 2023Licensure
30 Aug 2023Licensure
Found multiple deficiencies related to resident protections, care planning, discharge documentation, infection control, and vaccination practices. The survey cited failures in timely notices, restraint management, comprehensive care planning, discharge summaries, wound care hygiene, and vaccine administration.
NFPA 99 6.3.4.1; 6.3.3.2Electrical Systems - Maintenance and Testing
NFPA 110Electrical Systems - Essential Electric System
NFPA 99 11.3.4.1; 11.3.4.2Gas Equipment - Cylinder and Container Storage
29 Aug 2023Life Safety
29 Aug 2023Life Safety
Identified two life safety deficiencies: combustible storage near the water heater in the maintenance room and the use of a portable electric heater plugged into a power strip.
2006 International Mechanical Code, Section 304.1; WDH Chapter 3 Construction Rules and Regulations for Healthcare FacilitiesLife Safety - Int'l Mechanical Code
2006 International Fire Code 605.10.2State Miscellaneous Life Safety
17 Jan 2023Revisit
17 Jan 2023Revisit
Investigators found no deficiencies after a follow-up review and confirmed compliance with all regulations.
17 Nov 2022Complaint
17 Nov 2022Complaint
Investigated complaint identified deficiencies in timely completion of resident assessments (annual and after significant change) and in urinary catheter management, increasing risk of adverse outcomes.
42 CFR 483.20(b)(1)(2)(i)(iii) and 42 CFR 483.20(b)(2)Comprehensive Assessments & Timing
42 CFR 483.20(b)(2)(ii)Comprehensive Assessment After Significant Change
42 CFR 483.25(e)(1)-(3)Bowel/Bladder Incontinence, Catheter, UTI
21 Oct 2022Revisit
21 Oct 2022Revisit
Verified that all previously cited deficiencies were corrected and no new noncompliance was found.
20 Oct 2022Revisit
20 Oct 2022Revisit
Verified compliance after a follow-up visit; prior deficiencies were corrected and no new issues were found.
12 Aug 2022Life Safety
12 Aug 2022Life Safety
Found multiple life-safety deficiencies, including egress doors not releasing with the required force and gaps in testing/maintenance of alarms, sprinklers, dampers, and fire doors.
483.21(b)(1)Develop/Implement Comprehensive Care Plan
483.25(d)(1)-(2)Free of Accident Hazards/Supervision/Devices
483.80(h)COVID-19 Testing-Residents & Staff
26 Aug 2021Revisit
26 Aug 2021Revisit
Verified that previously cited deficiencies were corrected and no new noncompliance was found.
18 Aug 2021Revisit
18 Aug 2021Revisit
Verified continued compliance with life safety standards after a revisit, with prior deficiencies corrected.
30 Jul 2021Complaint
30 Jul 2021Complaint
Investigated a complaint and COVID-19 infection control review and found no deficiencies.
30 Jun 2021Licensure
30 Jun 2021Licensure
Identified failures to develop individualized comprehensive care plans for two residents, with missing or incomplete documentation for behavior management and physical protection measures.
42 CFR 483.21(b)(1)Comprehensive Care Plans
29 Jun 2021Life Safety
29 Jun 2021Life Safety
Found multiple deficiencies in emergency preparedness and life-safety systems, including failure to update plans, missing contact information, and several fire safety and electrical issues.
42 CFR 483.73(a)Emergency Plan – annual review
42 CFR 483.73(c)(2)Emergency Officials Contact Information
NFPA 101 (2012) 8.3.3.1; NFPA 80 (2010) 5.2.1Means of Egress - General (Fire Doors)
NFPA 101, 19.2.2.2.4; 7.2.1.6.1.1Egress Doors
NFPA 101 19.3.2Hazardous Areas - Enclosure
NFPA 101 19.3.2.6(8)(a)Alcohol Based Hand Rub Dispenser (ABHR)
NFPA 13 6.2.7.1Sprinkler System - Installation
NFPA 110 8.3.7.1Electrical Systems - Essential Electric System
28 Jun 2021Revisit
28 Jun 2021Revisit
Found no deficiencies; all previously cited deficiencies were corrected and no new noncompliance was found.
29 Apr 2021Complaint
29 Apr 2021Complaint
Investigated a complaint and found failures to screen visitors and enforce infection prevention practices, including masking and vaccination status documentation, during the COVID-19 response.
42 CFR §483.80Infection prevention and control
08 Jan 2021Revisit
08 Jan 2021Revisit
Determined that all prior deficiencies were corrected and no new noncompliance was found.
08 Jan 2021Revisit
08 Jan 2021Revisit
Confirmed that all previous deficiencies were corrected and no new noncompliance was found.
13 Oct 2020Licensure
13 Oct 2020Licensure
Identified deficiencies in infection prevention and control, including failure to conduct an annual IPCP review and to maintain an incident recording system.
Type A§483.80(a)(4)A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility
Type A§483.80(f)Annual review
20 May 2020Licensure
20 May 2020Licensure
Found no deficiencies identified in a COVID-19 focused infection control survey conducted May 18-20, 2020.
10 Dec 2019Revisit
10 Dec 2019Revisit
Verified compliance after a follow-up visit; all deficiencies were corrected.
09 Dec 2019Revisit
09 Dec 2019Revisit
Verified all previously cited deficiencies were corrected.
14 Nov 2019Revisit
14 Nov 2019Revisit
Found that six of seven residents reviewed were prescribed psychotropic medications with no adequate justification or monitoring, and no system linked target behaviors to each medication.
§483.45(e)Psychotropic Drugs
13 Nov 2019Revisit
13 Nov 2019Revisit
Identified deficiencies in emergency preparedness training and testing; seven staff members were not trained and verification of training was not shown.
CFR 483.73(d)Emergency preparedness training and testing
13 Nov 2019Revisit
13 Nov 2019Revisit
Concluded that all prior deficiencies were corrected and back in compliance.
17 Sept 2019Life Safety
17 Sept 2019Life Safety
Identified a failure to maintain roof assemblies and rooftop structures per code, with a water leak observed in the kitchen.
2006 IBC, Section 1503.2Maintenance of roof assemblies and rooftop structures
17 Sept 2019Life Safety
17 Sept 2019Life Safety
Investigated multiple life-safety deficiencies involving emergency lighting, exit signage, and evacuation-related policies and training. Also noted issues with decorations and related NFPA standards.
NFPA 101, Life Safety Code, 2012 editionEmergency Lighting
NFPA 101, Life Safety Code, 2012 editionExit Signage
CFR 483.73(b)(3)Policies for Evacuation and Primary/Alternate Communication
CFR 483.73(d)EP Training and Testing
NFPA 701Combustible Decorations
12 Sept 2019Complaint
12 Sept 2019Complaint
Identified deficiencies across resident rights, assessment accuracy, care planning, medication management, nutrition, PASARR, and dental services.
§483.21(b)(1)Develop/Implement Comprehensive Care Plan
§483.21(b)(2)Care Plan Timing and Revision
§483.25(g)Nutrition/Hydration Status Maintenance
§483.45(c)Drug Regimen Review
§483.45(e)Free from Unnecessary Psychotropic Meds/PRN Use
§483.55(b)Routine/Emergency Dental Services in NF
12 Sept 2019Licensure
12 Sept 2019Licensure
Determined no deficiencies were found and compliance with state requirements was met.
27 Mar 2019Complaint
27 Mar 2019Complaint
Concluded the complaint investigation found no deficiencies.
12 Dec 2018Revisit
12 Dec 2018Revisit
Concluded that all previous deficiencies were corrected and no new noncompliance was found.
07 Dec 2018Revisit
07 Dec 2018Revisit
Found no deficiencies during the revisit; compliance was observed.
18 Oct 2018Revisit
18 Oct 2018Revisit
Concluded that all prior deficiencies were corrected after a revisit survey conducted on 2018-10-18.
17 Oct 2018Revisit
17 Oct 2018Revisit
Concluded that all deficiencies cited on 8/3/18 have been corrected.
11 Oct 2018Complaint
11 Oct 2018Complaint
Investigated a complaint and found significant medication errors and coordination problems around orders and care, including a resident’s death linked to delayed or missing antibiotic administration.
42 CFR 483.45(f)(2)Residents are free of significant medication errors
10 Sept 2018Life Safety
10 Sept 2018Life Safety
Investigated life-safety deficiencies and issued requirements for a Plan of Correction with deadlines.
NFPA 101Evacuation and Relocation Plan
NFPA 101Fire Alarm System - Testing and Maintenance
NFPA 101Egress Doors
10 Sept 2018Life Safety
10 Sept 2018Life Safety
Found deficiencies in egress locking, smoke detector testing, and fire plan documentation.
NFPA 101: 18.7.1.1–18.7.1.3; 18.7.2.1.2; 18.7.2.2; 18.7.2.3; 19.7.1.1–19.7.1.3; 19.7.2.1.2; 19.7.2.2; 19.7.2.3Fire safety plan not provided
06 Sept 2018Revisit
06 Sept 2018Revisit
Concluded that all previously cited life safety deficiencies were corrected; no new deficiencies were cited.
03 Aug 2018Licensure
03 Aug 2018Licensure
Determined there were no deficiencies.
02 Aug 2018Complaint
02 Aug 2018Complaint
Investigated a recertification survey and complaint intake, identifying multiple deficiencies in resident rights, funds access, transfers, assessments, wound care, medications, and equipment safety.
CFR( s ): 483.10(a)(1) 483.10(a)(2) 483.10(b) 483.10(b)(1) 483.10(b)(2)Resident Rights/Exercise of Rights
CFR( s ): 483.10(f)(10)Protection/Management of Personal Funds
CFR( s ): 483.15(c)(3) 483.15(c)(4) 483.15(c)(5) 483.15(c)(6) 483.15(c)(8)Notice Requirements Before Transfer/Discharge
CFR( s ): 483.15(d)(1) 483.15(d)(2)Notice of Bed Hold Policy Before/Upon Transfer
CFR( s ): 483.20(b)(1) 483.20(b)(2)(i) 483.20(b)(2)(iii)Comprehensive Assessments & Timing
CFR( s ): 483.20(b)(2)(ii)Comprehensive Assessment After Significant Change
CFR( s ): 483.20(c)Quarterly Assessments
CFR( s ): 483.25(b)(1)(ii)Treatment/Svcs to Prevent/Heal Pressure Ulcer
CFR( s ): 483.45(a) 483.45(b)(1) 483.45(b)(3)Pharmacy Services
CFR( s ): 483.45(e)(1) 483.45(e)(2) 483.45(e)(3) 483.45(e)(4) 483.45(e)(5)Free from Unnecessary Psychotropic Meds/PRN Use
CFR( s ): 483.90(d)(2)Essential Equipment, Safe Operating Condition
31 Jul 2018Life Safety
31 Jul 2018Life Safety
Investigated life-safety deficiencies related to doors and means of egress, including failure to maintain fire doors and corridor doors and to verify emergency generator battery tests.
NFPA 101 8.3.7.1; NFPA 80 5.2.2.4(6); 4.6.12.1Doors and Other Opening Protectives
NFPA 101 8.3.3.1; NFPA 80 5.2.2.4(6)Means of Egress - General
NFPA 101 19.3.6.3.6; NFPA 101 8.3Corridor - Doors
25 May 2018Revisit
25 May 2018Revisit
Investigated a revisit survey; all previous deficiencies were corrected and no new noncompliance was found.
20 Mar 2018Complaint
20 Mar 2018Complaint
Investigated a complaint about resident abuse and found the facility did not thoroughly investigate multiple abuse allegations and there were deficiencies in behavioral health care and related documentation.
CFR 483.12(c)(2)-(4)Investigations of alleged abuse
CFR 483.40Behavioral health services
21 Feb 2018Revisit
21 Feb 2018Revisit
Identified noncompliance with dietetic services due to an unqualified dietary supervisor who had not completed the required training by the compliance date; an extension was requested with a new target date.
Found no deficiencies identified during a complaint survey conducted on 2018-02-21.
13 Sept 2017Revisit
13 Sept 2017Revisit
Verified previous deficiencies were corrected and no new noncompliance was found.
30 Aug 2017Revisit
30 Aug 2017Revisit
Determined that prior deficiencies cited on 07/17/2017 were corrected and no new noncompliance was found.
20 Jul 2017Licensure
20 Jul 2017Licensure
Investigated the complaint and found a deficiency in dietetic services because the dietary manager was not qualified.
Type ACh 11 Sec 11 (a)(i) Dietetic ServicesDietetic services
20 Jul 2017Complaint
20 Jul 2017Complaint
Investigated a complaint and found multiple deficiencies related to resident rights, dining supervision, falls prevention, and care planning. The issues indicated substandard practices in several areas.
Type A—Grievance policy
—Dignity and respect; dining
—Falls prevention; resident safety
—Care planning and safety
—Administrative recordkeeping
17 Jul 2017Life Safety
17 Jul 2017Life Safety
Identified deficiencies in fire safety due to an inadequate sprinkler system and in smoking regulations due to missing no-smoking signage at entrances.
NFPA 101 Life Safety Code (2012 edition); NFPA 13 Installation of Sprinkler SystemsSprinkler system
Found no deficiencies identified during the complaint survey conducted on 2017-06-01.
12 Dec 2016Revisit
12 Dec 2016Revisit
Identified multiple regulatory deficiencies and confirmed they were corrected during the revisit.
483.10(b)(3), 483.10(d)(2)
483.10(e), 483.75(l)(4)
483.15(f)(1)
483.15(h)(2)
483.20(b)(2)(ii)
483.20(k)(3)(ii)
483.25
483.70(d)(1)(ii)
483.70(h)
483.25(a)(3)
12 Dec 2016Revisit
12 Dec 2016Revisit
Verified corrections to a previously reported deficiency; no new deficiencies were cited.
Ch 11 Sec 6 (a)(iv)Ch 11 Sec 6 (a)(iv)
01 Dec 2016Revisit
01 Dec 2016Revisit
Identified life-safety code deficiencies during a post-certification revisit.
NFPA 101Life Safety Code (NFPA 101)
NFPA 101Life Safety Code (NFPA 101)
LSCLife Safety Code (LSC)
LSCLife Safety Code (LSC)
01 Dec 2016Revisit
01 Dec 2016Revisit
Verified corrections to deficiencies from the prior survey; all issues were addressed.
06 Oct 2016Licensure
06 Oct 2016Licensure
Identified a hot water temperature control issue and non-certified dietary leadership, with accompanying dietary service deficiencies.
Ch 11 Sec 6 (a)(iv)Physical Environment
Ch 11 Sec 11 (a)(1)Dietetic Services
06 Oct 2016Complaint
06 Oct 2016Complaint
Found multiple deficiencies related to resident privacy, notification of medical appointments, activities programming, and discharge documentation.
Type A—Notification of medical appointments
Type A—Activity program
—Discharge summary
—Discharge summary
06 Oct 2016Life Safety
06 Oct 2016Life Safety
Identified multiple life-safety deficiencies, including smoke-resistive construction issues, exit access problems, and gaps in portable extinguishers and electrical safety measures.
NFPA 101 Life Safety Code, Sections 19.3.5.6 and 9.7.4.1Smoke-resistive construction/penetrations and door release
NFPA 101 Life Safety Code Standard; NFPA 10Portable fire extinguishers
NFPA 70 (National Electrical Code)Electrical wiring and equipment
NFPA 101 Life Safety Code (Exit access requirements)Exit access/egress
06 Oct 2016Life Safety
06 Oct 2016Life Safety
Investigated a complaint about safety compliance and found deficiencies in life-safety general requirements and fixture/luminaire safety, including exposed bulbs and faucet aerators.
NFPA Life Safety - NFPA General RequirementsNFPA General Requirements
NFPA Life Safety - NFPA General RequirementsNFPA General Requirements
08 Jun 2016Revisit
08 Jun 2016Revisit
Identified three regulatory deficiencies during the revisit; corrective actions were completed.
483.13(c)(1)(ii)-(iii), (c)(2)-(4)
483.13(c)
483.65
21 Apr 2016Complaint
21 Apr 2016Complaint
Identified deficiencies in abuse reporting and investigation, and in infection control practices, with need for policy updates and staff training.
—QAPI monitoring of abuse allegations
—Policies prohibiting mistreatment, neglect, abuse, and misappropriation; reporting
Verified corrections completed and found substantial compliance.
13 Nov 2015Revisit
13 Nov 2015Revisit
Determined that previously cited deficiencies were corrected.
08 Oct 2015Licensure
08 Oct 2015Licensure
The facility had deficiencies related to resident nutrition and weight loss risk, inadequate care-planning, and failure to consistently implement and monitor care plans and interventions.
Type A—Weight loss risk and nutritional interventions not followed
Type A—Care planning and weight/skin concerns not adequately addressed
Type A—Care plans and resident care standards
Type A—Updating and implementing care plans
Type A—Updated care plans and monitoring
Type A—Nutritional status and dietary management
08 Oct 2015Licensure
08 Oct 2015Licensure
Found there was no qualified supervisor of dietary services and no current dietary manager; interviews showed the position was vacant and a new manager would need training.
Type ACh 11 Sec 11 (a)(i)Dietetic Services
05 Oct 2015Life Safety
05 Oct 2015Life Safety
Investigated life-safety deficiencies, including missing self-closing devices on certain doors and removal of door hardware, and issues with exit access. Noncompliance with NFPA Life Safety Code standards was found.
NFPA 101, 2000, Sections 19.3.2.1 and 7.2.1.5.1NFPA 101 LIFE SAFETY CODE STANDARD
NFPA 101, 2000, Sections 19.2.9.1 and 7.9.3NFPA 101 LIFE SAFETY CODE STANDARD
05 Oct 2015Life Safety
05 Oct 2015Life Safety
Found continuous mechanical exhaust ventilation not established in the A Wing shower room; observed a window in the shower area.
IMC Life Safety - Intl Mechanical CodeIMC Life Safety - Intl Mechanical Code
15 Jul 2015Complaint
15 Jul 2015Complaint
Investigated a complaint; found no deficiencies.
21 Oct 2014Revisit
21 Oct 2014Revisit
Verified corrections were completed for multiple previously cited deficiencies; the revisit confirmed compliance with the cited requirements.
483.10(g)(1)
483.20(k)(3)(ii)
483.20(g) - (i)
483.25(b)
483.20(d), 483.20(k)(1)
483.25(m)(1)
483.30(e)
483.35(i)
483.40(b)
24 Sept 2014Complaint
24 Sept 2014Complaint
Found no deficiencies identified during the complaint investigations.
18 Sept 2014Revisit
18 Sept 2014Revisit
Investigated and found no deficiencies cited.
18 Sept 2014Revisit
18 Sept 2014Revisit
Verified that deficiencies reported earlier were corrected and actions completed.
18 Sept 2014Revisit
18 Sept 2014Revisit
Verified that previously reported deficiencies were corrected; follow-up confirmed corrections completed.
07 Aug 2014Complaint
07 Aug 2014Complaint
The Wyoming health regulator identified deficiencies including failure to post the most recent survey results in an area accessible to residents and concerns with residents’ assessments and care planning.
483.10(g)(1)RIGHT TO SURVEY RESULTS - READILY ACCESSIBLE
07 Aug 2014Life Safety
07 Aug 2014Life Safety
Identified deficiencies involving plumbing cross-connection in the kitchen sink and missing lens covers on lighting fixtures.
—Plumbing cross-connection—3-bay sink waste piping/air gap
—Lighting safety—lens covers
07 Aug 2014Licensure
07 Aug 2014Licensure
Investigated the dietary services and supervision; found deficiencies in meeting residents' nutritional needs and in establishing full-time qualified dietetic supervision.
Type A—Dietetic services and supervision
07 Aug 2014Life Safety
07 Aug 2014Life Safety
Identified life-safety deficiencies: corridors were not properly separated from use areas to resist smoke in several smoke compartments, and sprinkler pipe escutcheons were loose, creating unsealed penetrations.
42 CFR 483.70(a)Corridor separation and smoke resistance
NFPA 101 Life Safety Code, 2000 editionSprinkler piping escutcheons and penetrations properly sealed
31 Oct 2013Revisit
31 Oct 2013Revisit
Found multiple life-safety code deficiencies cited against the facility, related to NFPA 101 and the Life Safety Code, with several corrections dated in 2013.
NFPA 101, Life Safety CodeLife Safety Code deficiency
NFPA 101, Life Safety CodeLife Safety Code deficiency
NFPA 101, Life Safety CodeLife Safety Code deficiency
NFPA 101, Life Safety CodeLife Safety Code deficiency
NFPA 101, Life Safety CodeLife Safety Code deficiency
NFPA 101, Life Safety CodeLife Safety Code deficiency
NFPA 101, Life Safety CodeLife Safety Code deficiency
NFPA 101, Life Safety CodeLife Safety Code deficiency
25 Oct 2013Revisit
25 Oct 2013Revisit
Investigated a licensing matter and documented corrections completed for identified deficiencies.
16 Aug 2013Licensure
16 Aug 2013Licensure
Found noncompliance with dietary services qualifications; the dietary manager did not meet the required minimum qualifications. Enrollment evidence showed she was in a training program and not yet a registered dietitian.
Wyoming Rules and Regulations for Program Administration of Nursing Care Facilities, Chapter 11, Section 1 (Dietetic Services)Dietetic Services
15 Aug 2013Life Safety
15 Aug 2013Life Safety
Identified several life-safety deficiencies related to smoke barriers, fire drills, and flame-retardant materials. Noted inconsistencies in implementation of required protections and maintenance actions.
NFPA 101 LIFE SAFETY CODE STANDARDCorridor doors Smoke resistance
NFPA 101 LIFE SAFETY CODE STANDARDSmoke barrier walls smoke resistance
NFPA 101 LIFE SAFETY CODE STANDARDProvider's plan of correction cross-reference
NFPA 101 LIFE SAFETY CODE STANDARDFire drills are varied across shifts
NFPA 101 LIFE SAFETY CODE STANDARDCeilings and curtains flame retardancy
NFPA 101 LIFE SAFETY CODE STANDARDDraperies and curtains flame retardancy
NFPA 101 LIFE SAFETY CODE STANDARDJunction box covers in smoke compartments
15 Aug 2013Complaint
15 Aug 2013Complaint
The facility was found to have multiple deficiencies related to urinary catheter management, medical records, food safety, and overall resident care and safety. These issues indicate non-compliance with several care standards.
Type A—Urinary catheter management
Type A—Medical records safeguarding
Type A—Food procurement/sanitation
Type A—Resident information privacy
Type A—Care planning and corrective actions
24 Jan 2013Life Safety
24 Jan 2013Life Safety
Investigated a complaint from January 24, 2013 and found no deficiencies.
02 Aug 2012Licensure
02 Aug 2012Licensure
Identified multiple deficiencies in care planning, daily operations, and records, including failure to respond to resident concerns, weak activity scheduling, insufficient monitoring of resident status changes, improper PRN medications, and incomplete medical records.
—Continued From page 2
—Continued From page 3
—Continued From page 4
—Continued From page 10
—Continued From page 12
12 Jul 2012Complaint
12 Jul 2012Complaint
Investigated deficiencies related to resident assessment, care planning, and discharge processes. Identified failures to consistently complete and incorporate assessments, involve residents in planning, and document discharge information.
—Comprehensive assessment of residents' needs
—Delivery of services by qualified staff
—Resident participation in care planning
—Discharge planning
—Interventions added to care plans
—Assessment sign-off and validation
12 Jul 2012Life Safety
12 Jul 2012Life Safety
Identified two deficiencies related to door hardware and electrical outlet cover plates.
NFPA 101 Life Safety CodeDoors
NFPA 70 National Electrical CodeElectrical outlets - face plates
29 Feb 2012Complaint
29 Feb 2012Complaint
Found no deficiencies identified during a complaint investigation conducted on 2012-02-29.
07 Jul 2011Life Safety
07 Jul 2011Life Safety
Multiple life-safety and interior-finish deficiencies were observed, including improper wall coverings, unverified flame-spread ratings, incorrect door hardware, and several fire-protection system concerns.
NFPA 101 Life Safety Code StandardLife safety plan; smoke compartments
NFPA 101 Life Safety Code StandardFire alarm system policy and evacuation
NFPA 101 Life Safety Code StandardFire sprinkler system testing/maintenance
30 Jun 2011Licensure
30 Jun 2011Licensure
Identified a deficiency in dietetic services: the dietary manager was not certified.
Type AChapter 11, Section 11, Wyoming Rules and Regulations for Program Administration of Nursing Care Facilities, Dietetic ServicesDietetic Services
30 Jun 2011Licensure
30 Jun 2011Licensure
Identified deficiencies in resident care planning, daily activities, and safety-related processes during the evaluation.
03 Mar 2011Complaint
03 Mar 2011Complaint
Investigated seven complaint investigations and found no deficiencies.
12 Nov 2010Revisit
12 Nov 2010Revisit
Found deficiencies and required corrections during a follow-up visit.
483.13(c)
483.20
483.20(b)(2)(i)
483.20(d)(3), 483.10(k)(2)
483.25(c)
483.25(m)(1)
483.35(i)
483.60(b), (d), (e)
483.75(i)(2)(iv)
27 Oct 2010Revisit
27 Oct 2010Revisit
Investigated a complaint and found deficiencies that required corrections; subsequent corrections were completed.
26 Aug 2010Licensure
26 Aug 2010Licensure
Examined records and observations revealed deficiencies related to resident safety and care, including failure to report abuse promptly and shortcomings in assessments and care documentation.
24 Aug 2010Life Safety
24 Aug 2010Life Safety
Investigated a complaint about safety and maintenance deficiencies; observed several life-safety concerns including sprinkler/electrical issues and oxygen-related signage.
06 Aug 2010Revisit
06 Aug 2010Revisit
Investigated a complaint and verified that prior deficiencies were corrected.
19 Jul 2010Life Safety
19 Jul 2010Life Safety
Identified life-safety deficiencies related to exit access and fire alarm power; exit discharge paths were obstructed and detectors lacked power.
Type A42 CFR 483.70(a); NFPA 101 Life Safety Code StandardExit access and egress
NFPA 70, NFPA 72; NFPA 101 Life Safety Code StandardPower to detectors / Central smoke compartments
01 Oct 2009Revisit
01 Oct 2009Revisit
Investigated the follow-up survey and identified deficiencies, with several corrections completed and ongoing follow-up planned.
483.40(c)(1)-(2)
483.60(a),(b)
483.75(i)(1)
01 Oct 2009Revisit
01 Oct 2009Revisit
Identified several regulatory deficiencies and confirmed corrective actions were completed.
483.25(m)(1)Regulation 483.25(m)(1)
483.30(a)Regulation 483.30(a)
483.30(b)Regulation 483.30(b)
483.35(i)(2)Regulation 483.35(i)(2)
483.60(c)Regulation 483.60(c)
483.70(b); (d); (e)Regulation 483.70(b)(d)(e)
10 Aug 2009Revisit
10 Aug 2009Revisit
Found no deficiencies. Corrections completed for previously identified issues.
24 Jul 2009Licensure
24 Jul 2009Licensure
Investigation identified deficiencies in resident care, including injuries that were not promptly investigated and gaps in documentation and care planning. Multiple issues were observed across several areas of care and administration.
Type A—Continued From page 2 – injury
25 Jun 2009Licensure
25 Jun 2009Licensure
Investigated deficiencies in dietetic services; supervisory responsibility for the dietetic service was not assigned to a full-time qualified supervisor.
Type AState Rules and RegulationsSection 11. Dietetic Service
25 Jun 2009Complaint
25 Jun 2009Complaint
Investigated deficiencies in care planning and resident care documentation; multiple issues identified related to resident assessments and plans of correction.
24 Jun 2009Life Safety
24 Jun 2009Life Safety
The inspection identified several life-safety deficiencies, including problems with smoke control in corridors, smoke detectors, and dispenser placements near ignition sources.
NFPA 101 Life Safety Code Standard; 42 CFR 483.70(a)Corridor doors must resist smoke
NFPA 101 Life Safety Code Standard; 42 CFR 483.70(a)Fire alarm system and detectors
NFPA 101 Life Safety Code Standard; 42 CFR 483.70(a)Smoke detectors not installed in required locations
NFPA 101 Life Safety Code Standard; 42 CFR 483.70(a)Alcohol-based hand rub dispensers near ignition sources
11 Oct 2007Revisit
11 Oct 2007Revisit
Verified that deficiencies previously cited were corrected.
483.20(b)
483.20(b)(2)(i)
483.20(b)(2)(iii)
27 Sept 2007Revisit
27 Sept 2007Revisit
Investigated a follow-up after a prior survey and identified deficiencies in life safety and regulatory compliance. A summary of uncorrected deficiencies was sent.
08 Sept 2007Revisit
08 Sept 2007Revisit
Investigated deficiencies in resident assessments and QA oversight; RAPs and MDS assessments were not completed timely and quarterly reviews were not consistently performed.
—Resident Assessment - When Required
—Resident Assessment - When Required
—Quarterly Review Assessment
—Quarterly Review Assessment
—Quality Assurance Assessment and Assurance
09 Aug 2007Revisit
09 Aug 2007Revisit
Found life-safety deficiencies related to a delayed egress lock and several fire alarm system components.
NFPA 101 Life Safety Code StandardFire alarm system components
19 Jul 2007Complaint
19 Jul 2007Complaint
An investigation found multiple deficiencies in procedures for resident notification, privacy, medication management, and resident assessments. Several specific areas showed failures to meet regulatory requirements.
483.10(b)(11)NOTIFICATION OF CHANGES
483.10(a)PRIVACY AND CONFIDENTIALITY
UnknownSELF ADMINISTRATION OF DRUGS
UnknownPHYSICAL RESTRAINTS
UnknownCOMPREHENSIVE MDS ASSESSMENTS
UnknownQUARTERLY QA MEETINGS
UnknownQUARTERLY REVIEW ASSESSMENTS
UnknownRESIDENT ASSESSMENT
09 Jul 2007Complaint
09 Jul 2007Complaint
Identified a deficiency because nursing staff were not all licensed as required by the Wyoming Nursing Practice Act.
Wyoming Nursing Practice ActADMINISTRATION
13 Jun 2007Life Safety
13 Jun 2007Life Safety
Identified multiple life-safety deficiencies, including improper door hardware, inadequate emergency equipment testing, and missing or outdated policies and procedures.
Type ANFPA 101 LIFE SAFETY CODE STANDARDDoors protecting corridor openings
Type ANFPA 101 LIFE SAFETY CODE STANDARDDoor hardware/holding devices
Type ANFPA 101 LIFE SAFETY CODE STANDARDFire alarm system testing
Type ANFPA 101 LIFE SAFETY CODE STANDARDFire drill policy and training
01 Feb 2007Revisit
01 Feb 2007Revisit
Identified a deficiency requiring correction and conducted a follow-up to verify the action.
483.25(d)
22 Nov 2006Complaint
22 Nov 2006Complaint
Investigated deficiency in urinary incontinence care; observed inadequate treatment and services for residents including delayed toileting and lack of proper care.
483.25(d)URINARY INCONTINENCE
22 Jun 2006Revisit
22 Jun 2006Revisit
Cited multiple deficiencies related to resident rights and care standards during a post-certification revisit. The review was conducted to assess ongoing compliance.
483.13(a)
483.13(c)
483.15(a)
483.15(h)(2)
483.20(b)
483.20(g)
483.25(a)(3)
483.25(h)(2)
483.70(b)
483.75(b)
483.75(c)
07 Jun 2006Revisit
07 Jun 2006Revisit
Identified several Life Safety Code deficiencies; most corrections completed, with some uncorrected deficiencies remaining.
NFPA 101 / Life Safety CodeLife Safety Code deficiency
NFPA 101 / Life Safety CodeLife Safety Code deficiency
NFPA 101 / Life Safety CodeLife Safety Code deficiency
NFPA 101 / Life Safety CodeLife Safety Code deficiency
NFPA 101 / Life Safety CodeLife Safety Code deficiency
NFPA 101 / Life Safety CodeLife Safety Code deficiency
NFPA 101 / Life Safety CodeLife Safety Code deficiency
NFPA 101 / Life Safety CodeLife Safety Code deficiency
06 Apr 2006Licensure
06 Apr 2006Licensure
Identified deficiencies in tuberculosis testing and related recordkeeping, including missing second-step TB tests and gaps in staff TB documentation.
—State Standards - Section 5. Organization and Administration
06 Apr 2006Licensure
06 Apr 2006Licensure
An investigation identified deficiencies in resident rights, dignity, assessments, and infection control, along with improper use of restraints and other care-plan related issues.
483.13(c)STAFF TREATMENT OF RESIDENTS
483.15(a)DIGNITY
483.20COMPREHENSIVE ASSESSMENTS
483.15(h)(2)RESIDENT ASSESSMENT
483.25(e)(2)RANGE OF MOTION
483.65(a)INFECTION CONTROL
03 Apr 2006Life Safety
03 Apr 2006Life Safety
The facility showed life-safety deficiencies, including inadequacies with corridor door protections and lapses in maintenance and inspections for safety systems.
NFPA 101 LIFE SAFETY CODE STANDARDDoors protecting corridor openings in smoke barriers
NFPA 101 LIFE SAFETY CODE STANDARDKitchen/cooking facilities protection
03 Aug 2005Revisit
03 Aug 2005Revisit
Investigated follow-up and found corrections completed for previously cited deficiencies.
483.10(d)(3)
483.25(e)(2)
483.25(h)(1)
09 Jun 2005Revisit
09 Jun 2005Revisit
Identified deficiencies in resident privacy, ROM therapy, and accident-hazard controls.
483.10(d)(3)Free Choice
483.25(h)(2)Quality of Care
483.25(h)(1)Quality of Care
09 May 2005Revisit
09 May 2005Revisit
Concluded that corrections were completed after the revisit.
07 Apr 2005Licensure
07 Apr 2005Licensure
Investigated staff health-screening deficiencies and found that TB testing was not completed before residents could be contacted.
—Tuberculosis testing and health screening for staff
07 Apr 2005Licensure
07 Apr 2005Licensure
Investigated complaints about resident rights and privacy; identified deficiencies across several standards affecting privacy and quality of life.
Type A483.10(b)(3) FREE CHOICEFree Choice
22 Mar 2005Revisit
22 Mar 2005Revisit
Investigated follow-up and confirmed that corrective actions were completed.
24 Jan 2005Life Safety
24 Jan 2005Life Safety
Identified multiple life-safety code deficiencies, including issues with door protection, smoke barrier doors, and maintenance of fire suppression and life-safety systems.
NFPA 101 Life Safety Code StandardDoor protection in corridors
NFPA 101 Life Safety Code StandardSmoke barrier doors
NFPA 101 Life Safety Code StandardFire extinguisher maintenance
NFPA 101 Life Safety Code StandardSprinkler system lint and coverage
NFPA 101 Life Safety Code StandardSprinkler system maintenance
NFPA 101 Life Safety Code StandardLint and central exhaust corrections
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