I placed my dad here and I'm very pleased - the place is cozy, clean and feels like family. The staff (Susan included) are kind, professional and go above and beyond with personalized care, great therapy and social activities, and compassionate support through his transition. It's affordable with a flat rate and no surprises; overall a very good, welcoming option I would recommend.
Loved one of resident
Jul 2026
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Amenities
Healthcare services
Activities of daily living assistance
Assistance with bathing
Assistance with dressing
Assistance with transfers
Coordination with health care providers
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
Cable
Fully furnished
Housekeeping and linen services
Kitchenettes
Telephone
Wifi
Transportation
Transportation arrangement (medical)
Transportation to doctors appointments
Common areas
Beauty salon
Dining room
Garden
Outdoor space
Community services
Move-in coordination
Activities
Community-sponsored activities
Scheduled daily activities
Reviews
4.62·(77)
Overall rating
5
4
3
2
1
Care
4.9
Staff
4.9
Meals
5.0
Amenities
5.0
Value
5.0
Pros
Compassionate, resident-centered staff
Family-like, home-style atmosphere
Personalized dementia and end-of-life care
Strong rehabilitation and therapy services
Engaging activities and meaningful outings
Clean, well-maintained facility
Responsive, attentive management
Affordable flat-rate pricing
Smooth admission and transition support
Respectful treatment and dignity emphasis
Varied daily social opportunities
Well-regarded dining and meal service
Small-community scale with close staff–resident relationships
Continuity of long-term staff relationships
Cons
Primarily rehabilitation-focused orientation
Limited suitability for long-term skilled nursing
Limited local TV/channel and entertainment options
Variability in staff professionalism
Small size limits availability of specialized clinical services
Summary of reviews
Overall impression
Reviews portray Mission at the Villa Castle Rock as a small, home-style assisted living and short-term rehabilitation community with a strong emphasis on individualized, compassionate care. Families and residents frequently describe a warm, family-like atmosphere, continuity of caregivers, and staff who prioritize residents' dignity and quality of life. Praise centers on hands-on staff engagement, personalized care plans (including dementia and end-of-life support), and a willingness to accommodate resident preferences.
Care quality and clinical services
The facility receives consistent positive feedback for rehabilitation and therapy services; physical therapy and the rehab team are singled out for effective work that eases transitions back home. Clinical staff involvement in care planning and encouragement of engagement are highlighted as contributors to improved quality of life. Reviewers also emphasize attentive end-of-life care and dementia-sensitive approaches that preserve respect and comfort. At the same time, the community’s operational focus appears weighted toward short-term rehab and assisted-living–style services rather than long-term skilled nursing; prospective residents with high, ongoing medical needs should assess clinical capabilities against their long-term requirements.
Staff and management
Staff performance is the most prominent strength in the reviews. Care partners, aides, and leadership are described as compassionate, responsive, and invested in residents’ well-being. Several comments name specific managers as helpful and easy to work with, indicating responsive family communication and coordination with outside therapists. A small number of reviewers raised concerns about variability in staff professionalism, suggesting that experiences can differ by shift or individual — a factor families may want to discuss during tours and reference checks.
Dining, activities, and social life
Dining receives positive remarks in several accounts, with reviewers calling the food strong and the meal service supportive of residents’ needs. The program offers varied daily activities and social opportunities; examples include outings and specialized memory activities that families credited with improving mood and engagement. Socialization and a small-community vibe are consistent selling points for residents seeking companionship and routine. One noted operational shortcoming is limited local broadcast options and entertainment variety in the common areas — an easily verifiable amenity for visitors to check.
Facilities, pricing, and operational patterns
The facility’s small scale and home-like design are repeatedly praised for creating familiarity between staff and residents and for maintaining cleanliness. Pricing is described as affordable with a flat-rate structure and no hidden up-charges, which families cite as a financial advantage. The community is frequently characterized as delivering smooth admissions and transitions. Tradeoffs tied to the smaller size include fewer on-site specialized clinical services and less extensive entertainment/technology infrastructure than larger campuses.
Who this facility may suit
Mission at the Villa Castle Rock appears well suited to families seeking a compassionate, small-community assisted living or short-term rehabilitation setting focused on quality of life, social engagement, and dignity-preserving care. Prospective residents with long-term, high-acuity skilled nursing needs should confirm clinical capabilities elsewhere. During a visit, families may wish to observe staff–resident interactions across shifts, review specific therapy plans, and check entertainment/technology amenities to ensure alignment with expectations.
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Medicare Ratings
5·/ 5
Overall
Health Inspection
Staffing
Quality Measures
Ratings from the U.S. Centers for Medicare & Medicaid Services (Care Compare). View on Medicare.gov
Location
Mission at the Villa Castle Rock is located at 1445 Uinta Dr, Green River, WY, 82935.
About Mission at the Villa Castle Rock
Mission at the Villa Castle Rock sits right across from Castle Rock Medical Center at 1445 Uinta Dr in Green River, Wyoming, and this place has been around a while serving folks with different needs, whether someone needs assisted living, memory care, short-term rehab, or even skilled nursing around the clock, and it's got a community-based, non-profit approach that puts seniors right at the center of things, which is probably why folks give it an average rating of about 8.6 out of 10. Now, rooms come in studio, suite, one-bedroom, and two-bedroom layouts, most have private baths and walk-in showers, with kitchenettes, call lights for emergencies, and all the utilities-heat, water, electric, and trash-are included in the rent, so families don't have to sort through the bills every month. Meals come three times a day, and anyone who needs something special for their diet, like diabetic meals, can ask; meal times are flexible with a few menu options, which seems to make residents feel more at home, and the dining staff includes meal planners and chefs, so food's made with health in mind.
There's staff on duty 24 hours a day, nurses always nearby, and even on-site physicians around the clock, plus help with little things like bathing, laundry, and meds-housekeeping and laundry come every week. The whole place has fire safety set up in every room, and they don't skip the social side either, since there are always social activities, a few devotional gatherings off-site for spiritual folks, and transportation to medical appointments if needed. For senior residents needing healthcare, the list of services is pretty long: they help with diabetic care, non-ambulatory care, care for the intellectually disabled, wound care, pain management, incontinence care, and they handle IVs and PICC lines too, so families who worry about specific medical needs can rest easier. They offer occupational, speech, and physical therapy, with extra programs for post-stroke recovery or orthopedic care after hip or knee replacements, and they even help with palliative care and short-term therapy. There's a whirlpool tub for residents who need or enjoy it, and common areas inside where people can visit and relax out of their rooms.
People who live at Mission at the Villa Castle Rock get to be part of a community that tries to create a calm, relationship-focused setting; they're known for being a "culture change" community, which means they look at physical and emotional needs, and try to make folks feel safe and cared for, not just in body but in mind, too. The community offers help when someone's ready for the next step, with support like social services that help set up home health care or community transport if a person's going back home, and there's long-term placement for those who need to stay. The staff does regular health checks on residents, manages medications, and they support people who need independent living or board and care, so there's a little something for almost every stage-or every worry-that comes along with aging.
People often ask...
Mission at the Villa Castle Rock offers assisted living, memory care, and skilled nursing.
The full address for this community is 1445 Uinta Dr, Green River, WY 82935.
No, Mission at the Villa Castle Rock 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
al-310
Facility type
Assisted Living Facility
Inspection Reports
126
Reports
14
Type A Citations
0
Type B Citations
28
Complaints
21
Years
29 May 2025Revisit
29 May 2025Revisit
Verified that all deficiencies were corrected and compliance was achieved.
28 May 2025Revisit
28 May 2025Revisit
Verified that all prior deficiencies were corrected and no new noncompliance was found.
02 Apr 2025Complaint
02 Apr 2025Complaint
Investigated and found deficiencies in protecting residents from abuse and in infection control, including resident-to-resident abuse and improper handling of contaminated laundry.
CFR 483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
CFR 483.80(a)(1)-(a)(4); CFR 483.80(e); CFR 483.80(f)Infection Prevention and Control
01 Apr 2025Life Safety
01 Apr 2025Life Safety
Identified multiple deficiencies in emergency preparedness testing and life safety compliance, including failure to conduct required emergency plan exercises and unsafe conditions with cooking, gas, electrical, and oxygen storage.
NFPA 101 19.5.1.1; 18.5.1.1; 9.1.1; 9.1.2; NFPA 54 9.6.1.2Utilities - Gas and Electric
NFPA 99 9.3.7; 9.3.7.5.3Gas and Vacuum Piped Systems - Other (Oxygen Storage)
NFPA 99 6.4.4.1.2Electrical Systems - Essential Electric System
12 Mar 2024Revisit
12 Mar 2024Revisit
Concluded that all life safety deficiencies were corrected and no new noncompliance was found.
07 Mar 2024Revisit
07 Mar 2024Revisit
Verified compliance with all regulations. All previously identified deficiencies were corrected.
19 Jan 2024Licensure
19 Jan 2024Licensure
Investigated findings identified deficiencies in activities, bed rail entrapment risk assessment, behavioral health services, and medication labeling/storage.
CFR 483.24(c)(1)Activities Meet Interest/Needs
CFR 483.25(n)(1)-(4)Bed Rails
CFR 483.40Behavioral Health Services
CFR 483.45(g)(h)(1)(2) and 483.45(h)Label/Store Drugs and Biologicals
17 Jan 2024Life Safety
17 Jan 2024Life Safety
Identified a safety deficiency due to an oxygen cylinder left freestanding in a closet. Oxygen containers must be secured at all times.
Identified a deficiency due to an oxygen cylinder left freestanding in a closet, indicating a lack of proper securing.
NFPA 99, 2005 edition, Sec. 9.4.3.2; 9.7.2.3(11); 9.4.3.4; 9.4.4.1Oxygen cylinders not secured
17 Jan 2024Life Safety
17 Jan 2024Life Safety
Observed a laundry cart blocking an emergency exit corridor, hindering a clear means of egress; the obstruction was removed.
NFPA 101, 2012, 7.1.10; 42 CFR 483.90Means of Egress - General
05 Jan 2024Revisit
05 Jan 2024Revisit
Verified that all previously cited deficiencies were corrected and no new noncompliance was found.
29 Nov 2023Complaint
29 Nov 2023Complaint
Investigated a complaint of verbal abuse by staff; found a CNA told a resident 'If you don't stop screaming, I'm going to strangle you' and the CNA was terminated.
CFR 483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
24 Mar 2023Revisit
24 Mar 2023Revisit
Found no deficiencies. All previous deficiencies were corrected and compliance with regulations was maintained.
15 Dec 2022Revisit
15 Dec 2022Revisit
Verified compliance after a Life Safety Code revisit; all deficiencies previously identified were corrected and no new noncompliance found.
13 Dec 2022Complaint
13 Dec 2022Complaint
Found infection prevention and control failures, including improper linen handling and removal of a vital signs tower from a COVID-19 positive room. These practices could risk the spread of infection.
§483.80Infection Prevention and Control
08 Dec 2022Revisit
08 Dec 2022Revisit
Found no deficiencies. A follow-up visit confirmed prior issues were corrected and no new noncompliance was found.
06 Oct 2022Life Safety
06 Oct 2022Life Safety
Identified multiple life-safety deficiencies during a 2022 survey, including egress door performance, protection of cooking equipment, fire alarm labeling, gas piping safeguards, and emergency power room practices.
NFPA 101 19.2.2.2.1; 7.2.1.4.5Means of Egress - General
NFPA 54; NFPA 70; NFPA 101 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2; NFPA 54 9.6.1.2Utilities - Gas and Electric
NFPA 101 19.5.1; 9.1.3.1; NFPA 110 7.2; NFPA 99Electrical Systems - Other
06 Oct 2022Licensure
06 Oct 2022Licensure
Investigated multiple deficiencies, including failure to provide written transfer and bed-hold notices, poor food-safety practices, incomplete COVID-19 vaccination tracking, and training gaps for feeding assistants.
§483.15(c)(3)-(6)(8)Notice Requirements Before Transfer/Discharge
§483.15(d)(1)-(2)Notice of Bed Hold Policy Before/Upon Transfer
§483.80(i)(1)-(3)(i)-(x)COVID-19 Vaccination of Facility Staff
§483.95(h)Training for Feeding Assistants
06 Oct 2022Licensure
06 Oct 2022Licensure
Found no deficiencies. The survey determined compliance with state requirements.
27 May 2022Revisit
27 May 2022Revisit
Found no deficiencies and confirmed that prior issues were corrected during a follow-up visit.
08 Apr 2022Complaint
08 Apr 2022Complaint
Concluded that policies for staff with temporary delays in COVID-19 vaccination were missing.
§483.80(i)COVID-19 Vaccination of facility staff
30 Dec 2021Revisit
30 Dec 2021Revisit
Verified no deficiencies were found. All prior deficiencies were corrected.
16 Nov 2021Revisit
16 Nov 2021Revisit
Concluded that all life safety deficiencies identified earlier were corrected and the facility is back in compliance.
07 Oct 2021Licensure
07 Oct 2021Licensure
Identified multiple deficiencies across care planning participation, resident funds management, staff screening, catheter care planning, pressure ulcer prevention, psychotropic medication use, dietary staffing qualifications, and food safety practices.
§483.10(c)(2)-(3)Right to Participate in Planning Care
§483.10(f)(10)(iii)Accounting and Records of Personal Funds
§483.12(a)(3)-(4)Not Employ or Engage Staff w/ Adverse Actions
§483.21(b)(1)Develop/Implement Comprehensive Care Plan
§483.25(b)(1)Skin Integrity - Pressure Ulcers
§483.45(e)(1)-(5)Psychotropic Medications
§483.60(a)(1)-(2)Qualified Dietary Staff
§483.60(i)(1)-(2)Food safety requirements
07 Oct 2021Licensure
07 Oct 2021Licensure
Found no deficiencies. The survey determined compliance with state requirements.
06 Oct 2021Life Safety
06 Oct 2021Life Safety
Found multiple life-safety deficiencies including hazardous-area enclosure doors not self-closing, illegible hydraulic signs, a double-door corridor issue, and oversized gas cylinder storage in a noncompliant area.
NFPA 101 19.3.2.1.3Hazardous Areas - Enclosure
NFPA 101 19.3.5.1; 9.7; NFPA 13 24.5.1Sprinkler System - Installation
NFPA 101 19.3.6.3.5Corridor - Doors
NFPA 99 11.3.1; 5.1.3.3.2(4)Gas Equipment - Cylinder and Container Storage
02 Sept 2021Complaint
02 Sept 2021Complaint
Investigated the complaint and a COVID-19 infection control review and found no deficiencies.
14 Jul 2021Revisit
14 Jul 2021Revisit
Concluded that all previously cited deficiencies were corrected and no new noncompliance was found.
27 May 2021Licensure
27 May 2021Licensure
Identified missing annual RN assessments for two residents and absence of any other RN assessments in the medical records.
—Annual RN assessments documentation
27 May 2021Complaint
27 May 2021Complaint
Found no deficiencies. The complaint and COVID-19 infection control review found no deficiencies.
17 Dec 2020Licensure
17 Dec 2020Licensure
Found no deficiencies identified during a COVID-19 infection control survey conducted on 12/16/20 through 12/17/20.
10 Nov 2020Revisit
10 Nov 2020Revisit
Confirmed all previous deficiencies were corrected and no new noncompliance was found.
29 Sept 2020Licensure
29 Sept 2020Licensure
Investigated the infection control survey and found no deficiencies.
24 Sept 2020Revisit
24 Sept 2020Revisit
Found that all prior deficiencies were corrected and compliance was restored.
03 Sept 2020Revisit
03 Sept 2020Revisit
Concluded that all previously cited life safety code deficiencies were corrected after a revisit survey. The location is back in compliance.
02 Sept 2020Revisit
02 Sept 2020Revisit
Verified that previously cited deficiencies were corrected and no new noncompliance was found.
22 May 2020Licensure
22 May 2020Licensure
Investigated a COVID-19 focused infection control survey and found no deficiencies.
12 Mar 2020Complaint
12 Mar 2020Complaint
Investigated a resident care issue and found gaps in nursing assessments and documentation for incidents and changes in condition.
Type AWyoming Rules and Regulations for Program Administration of Assisted Living Facilities, Chapter 12Resident assessment and documentation requirements
12 Mar 2020Complaint
12 Mar 2020Complaint
Investigated deficiencies found in notifying resident representatives of transfers, accuracy of MDS assessments, timely removal of a catheter, and sanitary practices in food service.
CFR 483.10(g)(14)Notify of Changes (Injury/Decline/Room, etc.)
CFR 483.20(g)Accuracy of Assessments
CFR 483.25(e)Bowel/Bladder Incontinence, Catheter, UTI
Determined the facility was in compliance with state requirements.
12 Feb 2019Life Safety
12 Feb 2019Life Safety
Identified deficiencies in means of egress maintenance and fire alarm system testing/maintenance; emergency preparedness was found compliant.
NFPA 101 Life Safety CodeMeans of Egress - General
NFPA 101 Life Safety CodeFire Alarm System - Testing and Maintenance
08 Aug 2018Complaint
08 Aug 2018Complaint
Investigated a complaint survey and found no deficiencies.
03 May 2018Complaint
03 May 2018Complaint
Investigated a complaint and found no deficiencies identified.
19 Mar 2018Revisit
19 Mar 2018Revisit
Concluded that all prior deficiencies were corrected and no new noncompliance was found.
15 Feb 2018Revisit
15 Feb 2018Revisit
Verified no new noncompliance and found overall compliance with all regulations surveyed during the 2018-02-15 revisit.
15 Feb 2018Revisit
15 Feb 2018Revisit
Conducted a revisit and found no new noncompliance. Compliance with all regulations surveyed was confirmed.
18 Dec 2017Revisit
18 Dec 2017Revisit
Found no deficiencies. All prior deficiencies were corrected.
14 Dec 2017Licensure
14 Dec 2017Licensure
Identified multiple deficiencies across resident rights, care planning, safety, and supporting systems. Findings included incomplete risk assessments, deficient care plans, failures in infection prevention, food safety, and bed rail safety, with several outdated or missing directives.
Type A§483.10(c)(6); §483.10(c)(8); 42 CFR Part 489 Subpart IRight to accept or refuse medical treatment; Advance directives
Type A§483.24; §483.25; §483.40; §483.10Care planning; Services to attain/maintain well-being; Resident rights
Type A§483.21(b)(2)(i)-(iii)Care Plan Timing and Revision
Type A§483.60(i)(1)(2)Food safety requirements
Type A§483.80(a)(1)(2)(4)(e)(f)Infection prevention and control
Type A§483.90(d)(3)Bed safety; prevention of entrapment
14 Dec 2017Licensure
14 Dec 2017Licensure
Investigated and determined compliance with state requirements after a survey conducted 12/11/2017 through 12/14/2017.
13 Dec 2017Life Safety
13 Dec 2017Life Safety
Inspector identified multiple deficiencies affecting life-safety and facility systems, including inconsistent exit signage, inadequate egress signage, and problems with electrical and related safety systems.
42 CFR 483.70(a); NFPA 101 Life Safety CodeMeans of Egress
NFPA 101 Life Safety CodeExit Signage
NFPA 101 Life Safety CodeContinued deficiency – exits/egress
NFPA 101; NFPA 70 (general electrical standards)HVAC/Electrical – Essential Electric System
NFPA 101; NFPA 70 (Electrical Systems)Electrical Systems – Essential Electric System
NFPA 101; NFPA 99 (Electrical Systems)Electrical Systems – Essential Electric System (Battery/Backups)
NFPA 101; NFPA 99Electrical Systems – Essential Electrical System
13 Dec 2017Life Safety
13 Dec 2017Life Safety
Identified deficiencies in life-safety door maintenance and plumbing code compliance, including missing water-hammer arrestors on laundry equipment.
NFPA Life Safety Code (NFPA 101), 2006 edition, Sections 32.2.2.5.6 and 7.2.1.4.5NFPA Life Safety - NFPA Doors
IPC Life Safety – Int’l Plumbing CodeIPC Life Safety - Int’l Plumbing Code
13 Dec 2017Life Safety
13 Dec 2017Life Safety
Determined in compliance with all requirements after an emergency preparedness survey.
07 Nov 2017Licensure
07 Nov 2017Licensure
Found a deficiency where services provided outside the agency lacked a proper contract and documentation for a resident's outside services.
Investigated a complaint; found no deficiencies. The review covered a two-day survey conducted in September 2017.
27 Apr 2017Revisit
27 Apr 2017Revisit
Confirmed compliance after follow-up surveys; deficiencies were corrected by March 2017.
05 Apr 2017Revisit
05 Apr 2017Revisit
Concluded the deficiencies from prior recertification surveys were corrected and the provider was put back into compliance after follow-up visits.
05 Apr 2017Revisit
05 Apr 2017Revisit
Determined the site was brought back into compliance following follow-up surveys.
20 Jan 2017Licensure
20 Jan 2017Licensure
Investigated issues found deficiencies in housekeeping, maintenance, and care planning, with multiple areas in disrepair and care plans not addressing identified needs.
483.10(i)(2)Housekeeping and Maintenance Services
483.20(b)(1)Comprehensive Assessments
483.60(d)(1)Develop Comprehensive Care Plans
483.60(i)(1)Procure food from sources approved or considered satisfactory by federal, state, or local authorities
20 Jan 2017Licensure
20 Jan 2017Licensure
Observed unsanitary conditions in animal enclosures, including two bird cages and an aquarium; cleaning practices and frequency were not adequate.
Investigated life-safety deficiencies related to exit signage and closet sprinkler protection. Found exit signs were not durable and closets lacked required sprinkler protection per NFPA standards.
NFPA 101 - Section 19.2.10.1; NFPA 13 - Section 1-6.1Exit signage and sprinkler system installation
NFPA 101 - Section 19.3.5.1 and 9.7.4.1; NFPA 13 - Section 1-6.1NFPA 101 Exit signage; NFPA 13 Sprinkler System
19 Jan 2017Life Safety
19 Jan 2017Life Safety
Identified a life-safety deficiency: the oxygen storage room lacked a fire-rated door and frame, despite staff belief that a rated door existed.
2006 IFC - Section 3006.2; 2006 IFC - Table 105.6.8Fire-resistance rating and door/frame requirements for oxygen storage and life safety
19 Jan 2017Revisit
19 Jan 2017Revisit
Investigated deficiencies identified in two surveys; the provider was put back into compliance after follow-up visits.
26 Jul 2016Complaint
26 Jul 2016Complaint
Found no deficiencies identified in the complaint investigation. The survey occurred on 7/25/2016 through 7/26/2016.
18 Mar 2016Revisit
18 Mar 2016Revisit
Identified two deficiencies during a post-certification revisit and documented corrective actions as completed.
483.15(h)(2)
483.25(i)
18 Mar 2016Revisit
18 Mar 2016Revisit
Investigated deficiencies previously reported; corrections for those deficiencies were completed.
—
25 Feb 2016Revisit
25 Feb 2016Revisit
Cited a life safety code deficiency related to NFPA 101 that was corrected on 2016-02-18.
NFPA 101Life safety code standard
LSCLife Safety Code deficiency
28 Jan 2016Licensure
28 Jan 2016Licensure
Found failure to keep hot water temperatures at or below 110 degrees Fahrenheit in multiple resident areas.
Type A—Shower/bath and resident lavatories shall be set to provide water temperature not to exceed 110 degrees Fahrenheit
28 Jan 2016Licensure
28 Jan 2016Licensure
Found deficiencies in cleanliness and maintenance, including damaged flooring and wall surfaces, and in medication documentation and review.
—Cleanliness and maintenance of living areas and bathrooms
—Medication management – PRN documentation and review
27 Jan 2016Life Safety
27 Jan 2016Life Safety
Investigated the complaint and found an exit door could not open to the required minimum width because of snow and ice outside the door.
2000 NFPA 101, Sections 19.2.2.2.1 and 7.2.1.4.5; NFPA 101 Life Safety Code StandardExit access width not met / door failed to maintain required width
20 Nov 2014Licensure
20 Nov 2014Licensure
The investigation found deficiencies in updating resident care plans, weaknesses in infection control, and inadequate maintenance of wander-alert devices.
Identified noncompliance with state nursing home regulations based on a survey conducted from 11/17/2014 through 11/20/2014. The survey determined the facility was in compliance with state requirements.
—LIC REGs FOR NURSING HOMES
19 Nov 2014Life Safety
19 Nov 2014Life Safety
Found serious life-safety deficiencies including a non-self-closing door, missing and improperly scheduled fire drills, and lack of documented inspections for life-safety systems and generators.
NFPA 101 Life Safety Code Standard (door self-closing requirement, NFPA 101 18.3.2)Door self-closing deficiency observed
NFPA 101 Life Safety Code StandardFire drills not properly conducted or documented
NFPA 101 Life Safety Code Standard; NFPA 72Testing requirements not understood or documented
NFPA 101 Life Safety Code Standard; NFPA 25Automatic sprinkler system testing not documented
NFPA 101 Life Safety Code Standard; NFPA 25Weekly generator inspections not documented
19 Nov 2014Life Safety
19 Nov 2014Life Safety
Identified noncompliance with construction/remodeling rules and life-safety guidelines.
Found deficiencies related to regulatory requirements; corrections completed by the dates shown.
483.15(h)(2)
483.20(g) - (i)
09 Dec 2013Revisit
09 Dec 2013Revisit
Verified corrections completed.
03 Oct 2013Licensure
03 Oct 2013Licensure
Identified an outbreak of respiratory illness and found it was not reported to state health authorities.
Ch 11 Sec 6 (b)(iii)Physical Environment
03 Oct 2013Licensure
03 Oct 2013Licensure
Identified deficiencies in housekeeping and maintenance services and in the accuracy of resident assessments.
—Housekeeping and maintenance services
—Assessment accuracy/coordination/certified
02 Oct 2013Life Safety
02 Oct 2013Life Safety
Investigated life-safety concerns: exit corridors were obstructed and a manual pull station was blocked, indicating noncompliance.
42 CFR 483.70(a); NFPA 101 Life Safety Code StandardRequirements for Long Term Care Facilities / Life Safety Code
NFPA 101 Life Safety Code StandardLife Safety Code Standard (NFPA 101)
14 Nov 2012Revisit
14 Nov 2012Revisit
Investigated a facility's compliance and found multiple deficiencies requiring correction.
483.20(b)(2)(ii)
483.20(k)(3)(i)
483.25(a)(3)
483.25(c)
483.25(h)
17 Oct 2012Revisit
17 Oct 2012Revisit
Identified life-safety deficiencies and completed corrections during the follow-up visit.
NFPA 101 Life Safety CodeLife Safety Code
NFPA 101 Life Safety CodeLife Safety Code
NFPA 101 Life Safety CodeLife Safety Code
NFPA 101 Life Safety CodeLife Safety Code
NFPA 101 Life Safety CodeLife Safety Code
NFPA 101 Life Safety CodeLife Safety Code
NFPA 101 Life Safety CodeLife Safety Code
30 Aug 2012Licensure
30 Aug 2012Licensure
Identified multiple deficiencies relating to resident care, wound care, sanitation, food service, and safety with corrective actions required.
Type A483.20(k)(3)(i)Services by qualified personnel / Plan of care
Type A403.25(d)Treatment / Services to prevent or heal wounds
403.25(c)Treatment / Services to prevent or heal pressure sores
Type A—Sanitary conditions / environment maintenance
Type A483.60Sanitary handling of food / meals
30 Aug 2012Licensure
30 Aug 2012Licensure
Concluded no deficiencies were found; the facility was in compliance with state requirements.
29 Aug 2012Life Safety
29 Aug 2012Life Safety
Investigated a safety concern and found life-safety deficiencies, including an uninstalled closure and outdated extinguisher tests.
NFPA 101 LIFE SAFETY CODE STANDARDContinued From page 2 – Emergency lighting and maintenance of portable extinguishers
31 Aug 2011Revisit
31 Aug 2011Revisit
Investigated deficiencies cited during a follow-up visit and noted corrections completed on 07/09/2011.
15 Aug 2011Revisit
15 Aug 2011Revisit
Investigated life safety code deficiencies; corrections were completed for the cited issues.
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
09 Jun 2011Licensure
09 Jun 2011Licensure
Investigated a complaint about resident care and found multiple deficiencies in residents’ rights, medication management, and care planning.
483.10(d)Resident Self-Administration of Medications
483.15(a)Dignity and Respect of Individuality
483.15(a)Dignity and Respect of Individuality
483.60(c)Drug Regimen Review
483.75(i)Administration
09 Jun 2011Licensure
09 Jun 2011Licensure
Confirmed compliance with State Rules and Regulations after a re-certification survey conducted June 6-9, 2011.
07 Jun 2011Life Safety
07 Jun 2011Life Safety
Identified multiple life-safety and facility maintenance deficiencies, including improper fire alarm testing, sprinkler system issues, electrical safety concerns, and non-compliant furnishings.
NFPA 101 Life Safety Code; NFPA 70 National Electrical CodeLife safety and electrical system testing/maintenance deficiencies
NFPA 72; NFPA 70Fire alarm system monthly testing/activation deficiencies
NFPA 25; NFPA 13Sprinkler head placement and periodic audits
—Electrical outlets – GFCI protection
—Curtains and mattresses safety standards
02 Sept 2010Revisit
02 Sept 2010Revisit
Verified corrections were completed for previously cited deficiencies during the follow-up visit.
483.20(k)(3)(ii)
483.25
483.25(a)(3)
483.25(d)
02 Sept 2010Revisit
02 Sept 2010Revisit
Investigated and found corrections completed for deficiencies noted during the prior survey. Follow-up confirmed progress and compliance with required items.
01 Jul 2010Licensure
01 Jul 2010Licensure
Identified deficiencies in resident care including inadequate documentation of pain management and failures in toileting/incontinence care, with insufficient oversight to ensure care plans are followed.
42 CFR 483.25Provide care/services for highest well-being
42 CFR 483.25Provide care/services for highest well-being
42 CFR 483.25Provide care/services for highest well-being
29 Jun 2010Life Safety
29 Jun 2010Life Safety
Identified several life-safety and electrical deficiencies, including obstructed sprinklers, improper signage around oxygen use, and generator/electrical wiring issues.
NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code Standard - Sprinkler system maintenance/obstructions
NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code Standard - Maintenance of automatic sprinkler systems
NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code Standard - Signage related to oxygen use
NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code Standard - Generator testing
NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code Standard - Electrical wiring and equipment
17 Jul 2009Revisit
17 Jul 2009Revisit
Investigated and cited deficiencies related to resident rights and care during a post-certification revisit.
483.20(k)(3)(i)
483.25(a)(3)
483.25(d)
08 Jul 2009Revisit
08 Jul 2009Revisit
Investigated follow-up to a prior survey; corrective actions completed; a summary of uncorrected deficiencies was sent.
14 May 2009Licensure
14 May 2009Licensure
Found deficiencies in care planning, daily living support, hygiene, staffing, infection control, and pharmacy services, indicating noncompliance with required standards.
483.20(k)(3)(i)COMPREHENSIVE CARE PLANS
483.25(a)(3)ACTIVITIES OF DAILY LIVING
483.25(d)URINARY INCONTINENCE
483.30(e)NURSE STAFFING
483.65(b)(3)PREVENTING SPREAD OF INFECTION
483.60(a)(b)PHARMACY SERVICES
14 May 2009Licensure
14 May 2009Licensure
Concluded there were no state regulation deficiencies identified during a recertification survey. The survey occurred May 11-14, 2009.
12 May 2009Life Safety
12 May 2009Life Safety
Identified a life-safety deficiency where manual fire alarm pull stations were obstructed by plants, potentially hindering fire notification.
NFPA 101 Life Safety Code StandardPull stations unobstructed
23 Jun 2008Complaint
23 Jun 2008Complaint
Investigated a complaint and found substantial compliance with long-term care facility requirements.
30 May 2008Revisit
30 May 2008Revisit
Identified deficiencies related to resident rights and regulatory compliance; corrective actions were completed.
483.20, 483.20(b)
483.20(c)
483.30(e)
483.75(i)(1)
483.35(i)(2)
01 May 2008Revisit
01 May 2008Revisit
Identified multiple life-safety/code deficiencies; several corrections were completed by 04/18/2008, with follow-up conducted on 05/01/2008.
—Life Safety Code deficiency (NFPA 101)
—Life Safety Code deficiency (NFPA 101)
—Life Safety Code deficiency (NFPA 101)
—Life Safety Code deficiency (NFPA 101)
—Life Safety Code deficiency (NFPA 101)
—Life Safety Code deficiency (NFPA 101)
—Life Safety Code deficiency (NFPA 101)
—Life Safety Code deficiency (NFPA 101)
13 Mar 2008Licensure
13 Mar 2008Licensure
Identified deficiencies in resident assessments, nurse staffing postings, meal frequency, and infection control practices.
483.20COMPREHENSIVE ASSESSMENTS
483.20(c)QUARTERLY REVIEW ASSESSMENTS
483.30(e)NURSE STAFFING
483.35(f)FREQUENCY OF MEALS
483.65(b)(3)PREVENTING SPREAD OF INFECTION
13 Mar 2008Licensure
13 Mar 2008Licensure
Identified a deficiency where one employee had not completed tuberculosis (TB) testing before resident contact, with the administrator holding multiple roles in the organization.
Section 5(b)(iv)(A)Tuberculin testing for employees prior to resident contact
10 Mar 2008Life Safety
10 Mar 2008Life Safety
Found life-safety deficiencies related to smoke barrier integrity and door operation, and related observations about conduit penetrations and staff awareness.
Investigated the follow-up after the survey and found no deficiencies.
24 Apr 2007Revisit
24 Apr 2007Revisit
Identified deficiencies citing federal regulations; corrections completed on follow-up.
483.10(b)(11)
483.25
483.25(a)(3)
24 Apr 2007Complaint
24 Apr 2007Complaint
Identified deficiencies in care planning and fall prevention; care plans did not fully address residents' needs and falls risks.
483.20(d), 483.20(k)(1)COMPREHENSIVE CARE PLANS
483.25(h)(2)ACCIDENTS
20 Apr 2007Revisit
20 Apr 2007Revisit
Investigated a complaint and found deficiencies; a follow-up revisit occurred on 2007-04-20.
09 Apr 2007Revisit
09 Apr 2007Revisit
Investigated the reported deficiencies and confirmed corrections completed for prior findings; follow-up actions were completed.
23 Feb 2007Licensure
23 Feb 2007Licensure
Investigated deficiencies found relating to resident privacy and confidentiality and to mail/written communications rights.
Type A483.10(e), 483.75(i)(4)Privacy and Confidentiality
Type A483.10(i)(1)Mail
21 Feb 2007Life Safety
21 Feb 2007Life Safety
Found several life-safety deficiencies related to fire barriers, smoke barriers, door hardware, and testing/maintenance practices.
NFPA 101 Life Safety Code StandardNFPA 101 Life Safety Code Standard
NFPA 101 Life Safety Code StandardNFPA 101 Life Safety Code Standard
NFPA 101 Life Safety Code StandardNFPA 101 Life Safety Code Standard
NFPA 101 Life Safety Code StandardNFPA 101 Life Safety Code Standard
NFPA 101 Life Safety Code StandardNFPA 101 Life Safety Code Standard
NFPA 101 Life Safety Code StandardNFPA 101 Life Safety Code Standard
25 Jan 2007Complaint
25 Jan 2007Complaint
Identified deficiencies in notifying residents and families about changes in condition and in providing and documenting appropriate resident care and services.
483.10(d)(11)NOTIFICATION OF CHANGES
—
—
483.25QUALITY OF CARE
20 Feb 2006Revisit
20 Feb 2006Revisit
Found no deficiencies.
15 Dec 2005Licensure
15 Dec 2005Licensure
Found multiple deficiencies in care planning and resident care, including incomplete assessments, incomplete care plans, and inadequate management of health issues such as continence, pressure sores, and medications.
483.20(b)Comprehensive Assessments
483.20(k)(3)(i)Comprehensive Care Plans
483.20(k)(3)(ii)Provider's Plan of Correction (cross-referenced to deficiencies)
483.25Quality of Care - Bowel/Continence
483.25(a)Activities of Daily Living
483.25(c)Pressure Sores
483.25(d)Urinary Incontinence
483.25(i)(1)Unnecessary Drugs
483.25(i)(1)Unnecessary Drugs
483.25(i)(2)Antipsychotic Drugs
483.25(d)Urinary Incontinence
02 Dec 2005Revisit
02 Dec 2005Revisit
Found no deficiencies.
05 Oct 2005Life Safety
05 Oct 2005Life Safety
Identified multiple deficiencies in fire safety, sprinkler maintenance, electrical safety, and signage during the visit.
NFPA 101 Life Safety Code 19.3.6.3Door protection
NFPA 101 Life Safety Code 19.3.7.3Smoke barrier penetration
NFPA 72Central station placard
NFPA 25Sprinkler system maintenance
NFPA 10Portable fire extinguishers
NFPA 70Electrical system installation
06 Jul 2005Complaint
06 Jul 2005Complaint
Investigated a complaint; found no deficiencies.
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