I feel truly at home here - the facility is spotless, safe, and lively with residents out and about. The staff are professional, compassionate, and attentive to residents and families; their personalized support and smooth transitions make this an easy place to recommend.
Current/former resident
Jul 2026
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Amenities
Healthcare services
Activities of daily living assistance
Assistance with bathing
Assistance with dressing
Assistance with transfers
Medication management
Healthcare staffing
24-hour call system
24-hour supervision
Meals and dining
Diabetes diet
Meal preparation and service
Special dietary restrictions
Room
Air-conditioning
Cable
Fully furnished
Housekeeping and linen services
Kitchenettes
Private bathrooms
Telephone
Wifi
Transportation
Community operated transportation
Transportation arrangement
Common areas
Beauty salon
Computer center
Dining room
Fitness room
Gaming room
Garden
Outdoor space
Small library
Wellness center
Community services
Concierge services
Fitness programs
Move-in coordination
Activities
Community-sponsored activities
Planned day trips
Resident-run activities
Scheduled daily activities
Reviews
4.63·(8)
Overall rating
5
4
3
2
1
Care
4.6
Staff
4.6
Meals
4.6
Amenities
4.6
Value
4.6
Pros
professional, well-trained staff
compassionate and caring caregivers
strong relationship-building with residents
home-like, comfortable environment
frequently recommended by families
encourages family visits and involvement
engaging activities (e.g., painting)
supportive staff during transitions
individualized/personalized care plans
consistent quality care
safe and secure setting
clean and well-maintained facility
positive, welcoming atmosphere
residents are active and out and about
attentive to residents and families
accommodating and flexible staff
professional and well-run operations
big-hearted, warm team
Cons
removal/reduction of therapy services mentioned
removal/reduction of assistance/services mentioned
occasional changes to services that concern families
Summary of reviews
Overall sentiment from these review summaries is strongly positive, with repeated emphasis on compassionate, professional staff and a homelike, safe environment. Multiple reviewers highlight the facility as being well-run and staffed by people who build relationships with residents—descriptions such as "professional," "compassionate," "big-hearted," and "attentive" appear throughout. Families frequently recommend the center and call it a "Godsend," which indicates a high level of trust and satisfaction with the day-to-day care and the facility’s culture.
Care quality emerges as a central strength. Reviews consistently note individualized and personalized care plans, along with quality clinical attention described as "excellent care" and "great care." Several comments indicate a smooth transition into the facility and that residents and families feel supported during moves. Reviewers specifically say residents feel at home and secure, which suggests both physical safety measures and consistent caregiving practices that promote resident confidence.
Staffing and interpersonal dynamics are standout themes. Reviewers repeatedly praise the staff for being compassionate, relationship-focused, and supportive to both residents and families. Staffing is described as attentive and accommodating; families mention staff support during visits and transitions, as well as responsiveness to family concerns. The operation of the facility is noted as professional, which, combined with descriptors like "big-hearted team," points to a balance of efficient management and warm bedside manner.
Facility environment and services are also positively reported. The building and common areas are called "very clean" and the atmosphere is described as pleasant—residents are observed "out and about," suggesting active programming and accessible communal spaces. At least one specific activity (painting) is mentioned, pointing to engagement opportunities that foster creativity and family participation. Safety and security are explicitly mentioned, further reinforcing the perception of a well-managed living environment.
Management and operations receive favorable mentions, but there is a limited pattern of concerns worth noting. A few summaries reference removal or reduction of therapy services and removal of assistance; while reviewers still often say "care otherwise fine," these mentions indicate that some families experienced changes to the level or type of services provided. The summaries do not provide detail about frequency, duration, or causes of these changes, but the repeated mention suggests it is the primary area of negative feedback across the reviews. Families may want clearer communication about any service adjustments, and prospective residents should ask management about typical therapy and assistance availability and policies for changes.
Notably absent from the summaries is substantial commentary on dining quality, medication management specifics, or pricing/financial matters. Because those topics are not raised, no positive or negative conclusions can be drawn from these reviews on those aspects. Given the overall tenor of the feedback, the strongest and most reliable impressions from these reviews center on excellent interpersonal care, cleanliness, safety, active programming, and professional operations, tempered by occasional service reductions that warrant clarification.
In conclusion, Westward Heights Care Center is consistently described as a compassionate, clean, and well-run facility where residents feel at home and families feel supported. The dominant themes—professional and caring staff, individualized attention, a welcoming atmosphere, and active engagement—make it highly recommended by those who reviewed it. Prospective residents and families should, however, ask specific questions about therapy and assistance services and how the facility communicates and manages any changes to those services to ensure expectations align with current offerings.
Reviews written on Mirador
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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
Westward Heights Care Center is located at 150 Caring Way, Lander, WY, 82520.
About Westward Heights Care Center
Westward Heights Care Center sits in the heart of Wyoming near Lander and offers a range of senior care services for up to 60 people, so whether someone's looking for independent living, assisted living, memory care for Alzheimer's and dementia, skilled nursing, or something like hospice or respite care, the staff tries to cover quite a bit under one roof, and they handle things like Medicare since the place is Medicare certified and has a partnership with CMS, which takes some of the paperwork and worry off families' hands. The care community has over 45 years of service to folks, winning more than 65 awards since 1996, including Silver and Bronze National Quality Awards from AHCA | NCAL and a five-star rating from Medicare.gov, so that tells a bit about how people outside the place have rated the care there, and being named a certified Great Place to Work through May 2026 shows the staff tend to stay, which can make a difference for people who like familiar faces. Residents have access to therapies like physical, speech, and occupational therapy along with restorative programs for everyone who needs to work on moving around or recovering from something, and for those who need extra help after a hospital stay, short-term rehab, long-term care, and skilled nursing are all here, and families who just need a little break can use respite care, while hospice care can also be arranged for people nearing the end of life. The community's been set up as a continuing care retirement community, so as care needs change, folks don't have to move to another building, and pricing and availability are listed on their website, along with photos and a way to arrange tours for anyone wanting to see the place in person or online, plus the Seniorly website gives a community score if someone's comparing places. The staff at Westward Heights Care Center focus on personalized care, making sure everyone feels important, and while details like room size or exact meals aren't spelled out here, the center does have therapies, adult day care, home health, and options for both independent and assisted living, so people have choices depending on what kind of help they need.
People often ask...
Westward Heights Care Center offers independent living, assisted living, and skilled nursing.
There are 18 photos of Westward Heights Care Center on Mirador.
The full address for this community is 150 Caring Way, Lander, WY 82520.
No, Westward Heights 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-201
Facility type
Nursing Home
Inspection Reports
117
Reports
21
Type A Citations
0
Type B Citations
21
Complaints
21
Years
16 May 2025Revisit
16 May 2025Revisit
Found no deficiencies. All prior deficiencies were corrected.
01 May 2025Revisit
01 May 2025Revisit
Verified that prior Life Safety Code deficiencies were corrected and no new noncompliance was found.
02 Apr 2025Life Safety
02 Apr 2025Life Safety
Found multiple life-safety deficiencies, including fire alarm testing gaps, uninspected dampers, unverified essential electrical system testing, and improper oxygen cylinder storage.
NFPA 72 (Fire Alarm and Signaling Code)Fire Alarm System - Testing and Maintenance
NFPA 101 (Life Safety Code) 19.5.2, 9.2.1; NFPA 90A; NFPA 80HVAC – Fire Damper Inspection and Testing
NFPA 99 (Health Care Facilities Code) 6.4.4.1.2.1; 6.4.4; NFPA 90A; NFPA 70Electrical Systems - Essential Electrical System (EES) Testing and Maintenance
NFPA 99 11.6.2.3Gas Equipment - Cylinder and Container Storage
27 Mar 2025Licensure
27 Mar 2025Licensure
Investigated and found deficiencies in psychotropic med management and infection control. The findings showed a lack of gradual dose reduction for trazodone in one resident and improper hand hygiene during meal service.
Investigated a complaint alleging abuse by a resident against another and a delay in a hip x-ray; found violations related to abuse protection and quality of care.
483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
483.25Quality of Care
21 Feb 2024Revisit
21 Feb 2024Revisit
Found no deficiencies and confirmed prior deficiencies were corrected.
12 Feb 2024Revisit
12 Feb 2024Revisit
Verified no deficiencies and full compliance with life safety requirements.
11 Jan 2024Licensure
11 Jan 2024Licensure
Investigated dialysis post-treatment monitoring and infection control practices; found inadequate monitoring of a dialysis access site and improper cleaning of glucometers between residents.
42 CFR 483.25(l)Dialysis
42 CFR 483.80Infection Prevention & Control
11 Jan 2024Licensure
11 Jan 2024Licensure
Concluded no violations were cited. Findings indicated compliance with state requirements.
09 Jan 2024Life Safety
09 Jan 2024Life Safety
Found deficiencies in fire alarm testing/maintenance documentation and weekly generator inspections, indicating noncompliance with life safety and essential electrical system requirements.
NFPA 101 19.3.4.1, 9.6.1.3; NFPA 70; NFPA 72Fire Alarm System - Testing and Maintenance
NFPA 99; NFPA 110; NFPA 111; NFPA 70Electrical Systems - Essential Electric System
04 Jan 2023Revisit
04 Jan 2023Revisit
Verified no deficiencies were found and compliance was confirmed after a Life Safety Code revisit.
22 Dec 2022Revisit
22 Dec 2022Revisit
Found no deficiencies after the follow-up visit; all prior deficiencies were corrected.
03 Nov 2022Licensure
03 Nov 2022Licensure
Investigated deficiencies in PRN psychotropic medication management and in staff COVID-19 vaccination compliance.
42 CFR §483.45(e)Psychotropic Drugs
42 CFR §483.80(i)COVID-19 Vaccination of Facility Staff
03 Nov 2022Licensure
03 Nov 2022Licensure
Found no deficiencies. A licensure survey conducted from 10/31/22 to 11/3/22 determined compliance with state requirements.
02 Nov 2022Life Safety
02 Nov 2022Life Safety
Observed deficiencies in cooking facilities protection, fire alarm testing, and essential electrical system maintenance.
NFPA 101 19.3.4.1, 9.6.1.3; NFPA 72 2010Fire Alarm System - Testing and Maintenance
NFPA 110 8.3.7.1; NFPA 70; NFPA 111; NFPA 70 700.10Electrical Systems - Essential Electric System
29 Dec 2021Revisit
29 Dec 2021Revisit
Verified that all previous deficiencies were corrected and no new noncompliance was found.
22 Nov 2021Revisit
22 Nov 2021Revisit
Verified that previously identified deficiencies were corrected and the site is back in compliance.
14 Oct 2021Licensure
14 Oct 2021Licensure
Found deficiencies in accurate reflection of resident health status, PASARR coordination, and nurse staffing postings, indicating noncompliance with federal requirements.
CFR 483.20(g)Accuracy of Assessments
CFR 483.20(e)(1)(2)Coordination of PASARR and Assessments
CFR 483.35(g)Posted Nurse Staffing Information
14 Oct 2021Licensure
14 Oct 2021Licensure
Found no deficiencies. Survey determined compliance with state requirements.
13 Oct 2021Life Safety
13 Oct 2021Life Safety
Identified multiple deficiencies in emergency preparedness and fire safety. Defects included missing shelter-in-place policy, inadequate training and testing, and several NFPA-fire-safety gaps.
CFR 483.73(b)(4)Policies/Procedures for Sheltering in Place
CFR 483.73(d)(1)Emergency preparedness training program
CFR 483.73(d)(2)Emergency preparedness testing
NFPA 101 18.1.1.1.3, 4.6.12.1General requirements – fire-resistive construction
NFPA 101 19.3.2.1.3, 19.3.5.9Hazardous areas - enclosure
NFPA 101 19.7.5.6Combustible decorations
NFPA 99 10.2.3.6, 10.2.4Electrical equipment - power cords and extension cords
21 Jul 2021Complaint
21 Jul 2021Complaint
Found no deficiencies.
07 Apr 2021Complaint
07 Apr 2021Complaint
Concluded no deficiencies were identified after reviewing a complaint and a COVID-19 focused infection control review.
01 Dec 2020Licensure
01 Dec 2020Licensure
Investigated a COVID-19 focused infection control survey and found no deficiencies.
14 May 2020Licensure
14 May 2020Licensure
Found no deficiencies identified during a COVID-19 focused infection control survey.
03 Sept 2019Revisit
03 Sept 2019Revisit
Verified the prior deficiency was corrected and no new noncompliance was found. No violations were cited and overall compliance was achieved.
28 Aug 2019Revisit
28 Aug 2019Revisit
Verified that all previously identified deficiencies were corrected and no new noncompliance was found. The entity was in compliance with all regulations surveyed.
25 Jul 2019Life Safety
25 Jul 2019Life Safety
The inspection identified safety deficiencies in electrical equipment usage and oxygen storage security.
NFPA 99; NFPA 70Power Strips and Extension Cords in patient care areas
NFPA 101Gas Equipment - Cylinder and Container Storage
24 Jul 2019Licensure
24 Jul 2019Licensure
Identified trip and entanglement hazards in resident rooms due to cords and tubing.
CFR 483.25(d)Accidents
24 Jul 2019Licensure
24 Jul 2019Licensure
Found no deficiencies.
27 Jun 2019Revisit
27 Jun 2019Revisit
Verified prior deficiencies were corrected and no new noncompliance was found. Overall compliance with applicable regulations was confirmed.
02 May 2019Complaint
02 May 2019Complaint
Investigated a complaint; found deficiencies in individualized care planning and timely toileting/incontinence care for a resident with urinary incontinence.
42 CFR 483.21(b)Comprehensive Care Plans
42 CFR 483.25(e)Bowel/Bladder Incontinence, Catheter, UTI
25 Sept 2018Revisit
25 Sept 2018Revisit
Found no deficiencies. All prior deficiencies were corrected and no new noncompliance was found.
05 Sept 2018Revisit
05 Sept 2018Revisit
Found no deficiencies; prior deficiencies were corrected and all regulations were met.
26 Jul 2018Life Safety
26 Jul 2018Life Safety
Identified multiple life-safety deficiencies, including failure to test and maintain the kitchen extinguishing system, inadequate or missing exit signage, and issues with smoke barriers and other building systems.
NFPA 96; NFPA 101 Life Safety CodeCooking Facilities
NFPA 101 Life Safety CodeExit Signage
NFPA 101 Life Safety CodeContinued From page 5 – Death in the event of a fire
NFPA 101 Life Safety CodeSubdivision of Building Spaces - Smoke Barrier Construction
NFPA 101 Life Safety Code; NFPA 70 (Electrical) CFRsElectrical Systems - Essential Electric System
NFPA 101 Life Safety CodeFire Alarm System - Testing and Maintenance
NFPA 101 Life Safety CodeSprinkler System - Maintenance and Testing
NFPA 101 Life Safety CodeFire Alarm System - Testing and Maintenance
26 Jul 2018Complaint
26 Jul 2018Complaint
Identified multiple deficiencies including improper transfer/discharge notices, inadequate handling of thickened liquids, and lapses in food safety practices.
§483.60(i)(1)-(i)(2)Food safety/ sanitation – preparation and serving
26 Jul 2018Licensure
26 Jul 2018Licensure
Determined the facility was in compliance with State requirements. No deficiencies were cited.
14 May 2018Revisit
14 May 2018Revisit
Confirmed no deficiencies; prior issues were corrected and no new noncompliance was found.
13 Mar 2018Complaint
13 Mar 2018Complaint
Investigated deficiencies in quality of care, including issues with anticoagulant management and related nursing documentation, with additional unrelated deficiencies identified.
CFR 483.25Quality of care
07 Sept 2017Revisit
07 Sept 2017Revisit
Investigated a revisit survey; all prior deficiencies were corrected and no new noncompliance found.
07 Sept 2017Revisit
07 Sept 2017Revisit
Investigated a revisit; all prior deficiencies were corrected and no new noncompliance was found.
14 Jul 2017Licensure
14 Jul 2017Licensure
Identified deficiencies in resident care planning, safety, and documentation.
14 Jul 2017Licensure
14 Jul 2017Licensure
Determined that the facility was in compliance with State requirements after a licensing survey conducted from 2017-07-10 to 2017-07-14.
11 Jul 2017Life Safety
11 Jul 2017Life Safety
Identified deficiencies related to sprinkler system coverage, supervisory signaling, and maintenance/testing of the sprinkler system.
NFPA 101 Life Safety Code - 19.3.5.1; 9.7.1Continued From page 3 - sprinkler coverage
NFPA 101 Sprinkler System - Supervisory SignalsSprinkler System – Supervisory Signals
NFPA 101 Sprinkler System - Maintenance and Testing; NFPA 25Sprinkler System – Maintenance and Testing
24 Oct 2016Revisit
24 Oct 2016Revisit
Investigated a complaint; identified multiple CMS deficiencies cited under federal regulations.
Identified three NFPA 101 Life Safety Code deficiencies; corrections completed by the follow-up.
NFPA 101K0018
NFPA 101K0052
NFPA 101K0130
11 Aug 2016Licensure
11 Aug 2016Licensure
Found deficiencies related to posting of advocacy contact information, confidentiality of resident health information, and privacy of resident records.
483.10(b)(5)-(10), 483.10(b)(1)Notice of rights, rules, services, charges
483.10(e)(6)Confidentiality of protected health information
483.20(k)(3)(ii)Personal privacy/confidentiality of records
11 Aug 2016Licensure
11 Aug 2016Licensure
Found no deficiencies. The survey determined compliance with state requirements.
09 Aug 2016Life Safety
09 Aug 2016Life Safety
Found multiple life-safety deficiencies including incomplete fire alarm testing/maintenance documentation, improper smoke compartment door operation, missing semi-annual kitchen hood fire suppression inspection records, and gaps in generator emergency lighting documentation.
NFPA 101 Life Safety Code (1998 edition), Section 8-3.1.1; NFPA 70; NFPA 72Fire alarm system testing and maintenance
NFPA 101 Life Safety Code (1998 edition), Section 8-3.1.1Maintenance of doors in smoke compartments
NFPA 96 (Kitchen Hood Fire Suppression) / NFPA 96, Section 8-2.1Kitchen hood fire suppression system inspection
NFPA 101 Life Safety Code; NFPA 70; NFPA 72Generator and emergency lighting documentation
NFPA 70 National Electrical CodeGFCI/wiring checks
07 Apr 2016Complaint
07 Apr 2016Complaint
Concluded no deficiencies identified in relation to the complaint investigation.
15 Oct 2015Revisit
15 Oct 2015Revisit
Investigated a life-safety code deficiency; the deficiency was corrected.
Ch 11 Sec 6 (b)(iii)Life Safety Code deficiency
15 Oct 2015Revisit
15 Oct 2015Revisit
Concluded substantial compliance after follow-up, with corrections completed for previously cited deficiencies.
01 Sept 2015Revisit
01 Sept 2015Revisit
Found no deficiencies.
01 Sept 2015Revisit
01 Sept 2015Revisit
Concluded that deficiencies previously reported were corrected; no new deficiencies cited.
09 Jul 2015Complaint
09 Jul 2015Complaint
Identified deficiencies across privacy, safety, sanitation, medication, and care planning; multiple areas failed to meet required standards.
—Privacy/Confidentiality of Records
—Housekeeping and Maintenance Services
—Develop Comprehensive Care Plans
—Provide Care/Services for Highest Well Being
—Free of Accident Hazards/Supervision/Devices
—Drug Regimens Free From Unnecessary Drugs
—Corridors Have Firmly Secured Handrails
09 Jul 2015Licensure
09 Jul 2015Licensure
Identified deficiencies in infection control reporting and dietetic services management.
Identified a lack of backflow protection for the chemical dispensing system due to a hose connection to the wall-mounted dispenser.
IPC Life Safety - Int'l Plumbing CodeBackflow prevention and plumbing cross-connection
08 Jul 2015Life Safety
08 Jul 2015Life Safety
Identified life-safety deficiencies related to exit accessibility and fire protection for cooking facilities, with follow-up actions noted.
Type ANFPA 101 Life Safety Code StandardExit access and egress
Type ANFPA 101 LIFE SAFETY CODE STANDARDCooking facilities protection / fire protection
08 Jul 2015Life Safety
08 Jul 2015Life Safety
Found noncompliance related to plumbing backflow prevention and overall life-safety system maintenance due to a hose connection installed without backflow prevention. Document described inadequate maintenance of plumbing systems per applicable codes.
IPC Life Safety - Int'l Plumbing CodeIPC Life Safety - Int'l Plumbing Code
28 Jan 2015Complaint
28 Jan 2015Complaint
Found no deficiencies.
23 Oct 2014Revisit
23 Oct 2014Revisit
Investigated a follow-up visit and found corrections completed for identified deficiencies.
22 Oct 2014Revisit
22 Oct 2014Revisit
Identified deficiencies in regulatory compliance with multiple items corrected; follow-up completed.
483.10(b)(11)
483.25(a)(3)
483.25(k)
483.35(i)
483.65
483.70(h)(2)
483.75(j)(2)(ii)
18 Sept 2014Revisit
18 Sept 2014Revisit
Investigated deficiencies under the Life Safety Code and confirmed corrections completed.
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
18 Sept 2014Revisit
18 Sept 2014Revisit
Verified corrections completed for previously reported deficiencies.
28 Aug 2014Licensure
28 Aug 2014Licensure
Identified safety and care deficiencies, including improper restraint use, inadequate falls supervision, and missing care-plan documentation.
—Seat belt use and supervision
—Abuse/Neglect prevention – reporting
—Falls prevention and supervision
—Heel irritation/breakdown care planning
10 Jul 2014Licensure
10 Jul 2014Licensure
Investigated deficiencies in resident care and safety; found inadequate daily living assistance and hygiene practices with ongoing hygiene concerns.
—Nursing/Personal care deficiencies
19 Jun 2014Life Safety
19 Jun 2014Life Safety
Investigated observed plumbing deficiencies and identified a lack of backflow prevention from a faucet connection, creating cross-connection risk.
International Plumbing Code, 2006 Edition, Section 608Backflow prevention
19 Jun 2014Life Safety
19 Jun 2014Life Safety
Identified life-safety deficiencies related to exit accessibility and electrical equipment; several items required corrective action.
NFPA 101 Life Safety CodeExit access/egress
NFPA 70 National Electrical CodeElectrical wiring and equipment
NFPA 101 Life Safety Code; NFPA 701Life Safety Code standard
30 May 2014Revisit
30 May 2014Revisit
Found no deficiencies.
27 Mar 2014Complaint
27 Mar 2014Complaint
Identified deficiencies in storage and handling of controlled substances and related recordkeeping.
The Comprehensive Drug Abuse Prevention and Control Act (Schedule II) and related controlled-substance management requirementsStorage and handling of controlled substances
26 Jul 2013Revisit
26 Jul 2013Revisit
Investigated the complaint and found no deficiencies.
26 Jul 2013Revisit
26 Jul 2013Revisit
Identified Life Safety Code deficiencies during a follow-up visit.
16 May 2013Licensure
16 May 2013Licensure
Investigated infection-control reporting deficiencies; found that an outbreak was not reported to all required entities.
—Infection control outbreak reporting
16 May 2013Licensure
16 May 2013Licensure
Identified multiple deficiencies related to resident care and staff practices, including inadequate bowel management, improper documentation, and lack of consistent care planning.
23 Apr 2013Complaint
23 Apr 2013Complaint
Determined that no deficiencies were identified during the complaint investigation.
22 Aug 2012Complaint
22 Aug 2012Complaint
Found no deficiencies after a complaint survey conducted on 2012-08-21 through 2012-08-22.
16 Aug 2012Revisit
16 Aug 2012Revisit
Investigated the prior findings and confirmed that all corrections were completed; follow-up indicated compliance.
09 Aug 2012Revisit
09 Aug 2012Revisit
Investigated and found deficiencies requiring follow-up actions.
01 Jun 2012Licensure
01 Jun 2012Licensure
Investigated deficiencies in resident assessment, care planning, nutrition, and oversight of medications; multiple deficiencies were identified.
Type A—Comprehensive assessment and care planning deficiencies
Type A—Resident assessment and care planning deficiencies
Type A—Quality of care deficiencies
Type A—Nutritional deficiencies and weight management
01 Jun 2012Licensure
01 Jun 2012Licensure
Verified compliance with state requirements after a survey conducted May 29 through June 1, 2012.
31 May 2012Life Safety
31 May 2012Life Safety
Identified life-safety and electrical-safety deficiencies, including improper use of electrical cords and surge protectors and issues with sprinkler head components.
NFPA 101 Life Safety Code StandardLife safety deficiency
NFPA 70, National Electrical Code, 1999 EditionElectrical safety – improper use of cords/protectors
NFPA 101 Life Safety Code StandardSprinkler system maintenance
NFPA 101 Life Safety Code StandardSprinkler system maintenance
Found deficiencies related to resident care planning, documentation, and infection control across multiple areas.
—Continued From page 2
—Care planning update
—Medication administration issue
—Infection control and hygiene practices
02 Feb 2012Complaint
02 Feb 2012Complaint
Investigated a complaint and found no deficiencies.
18 Aug 2011Revisit
18 Aug 2011Revisit
Investigated a follow-up visit and found no deficiencies cited.
04 Aug 2011Revisit
04 Aug 2011Revisit
Identified deficiencies requiring correction; all corrections were completed by 07/22/2011.
04 Aug 2011Revisit
04 Aug 2011Revisit
Verified follow-up actions after a prior review and documented corrections completed for multiple deficiencies.
17 Jun 2011Licensure
17 Jun 2011Licensure
The facility showed multiple deficiencies including inadequate medication self-administration safeguards, insufficient staff orientation, and problems with maintenance, dietary services, and emergency readiness.
42 CFR 483.10(n)Resident self-administration of medications
—Staff orientation and training
—Maintenance and sanitation
—Dietary/food service deficiencies
—Essential equipment and safe operating condition
—Quality Assurance and training
—Medication administration records and related practices
—Documentation of dietary and nursing procedures
—Emergency preparedness and drills
16 Jun 2011Life Safety
16 Jun 2011Life Safety
Investigated life safety issues and found a 1-inch penetration in the B Hall smoke barrier wall; noted penetrations should be inspected and sealed.
NFPA 101 Life Safety Code Standard; Building construction type and height (19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1)Life Safety Code standard – smoke barrier/penetration
12 May 2011Licensure
12 May 2011Licensure
Investigated a complaint that revealed multiple deficiencies in resident care, medication administration, care planning, and administrative oversight.
—Self-administration of medications
—Care planning and coordination for residents
—Care Area Assessments and QA oversight
—Narcotics management
—Pain management
—Prevention and treatment of skin integrity
25 May 2010Revisit
25 May 2010Revisit
Investigated corrective actions and confirmed completion of corrections following prior deficiencies.
22 Apr 2010Complaint
22 Apr 2010Complaint
Investigated and found multiple deficiencies involving CNA registry, medication handling, care planning, nutrition, staffing records, and infection control.
—Continued from page 2 – CNAs not properly listed or verified in CNA registry
—Medication labeling/ MAR verification deficiency
—Care planning/compliance with written care plans
—Clinical guidance/order clarification
—Wound care/dressing protocol
—Nutrition/dietary management
—Staffing data/Personnel
—Infection control/nursing procedures
—Medical records/Nursing documentation
22 Apr 2010Licensure
22 Apr 2010Licensure
Identified deficiencies in tuberculosis testing documentation and staff records.
Chapter 11, Section 5 (b)(iv)(A)Tuberculin testing for employees
20 Apr 2010Life Safety
20 Apr 2010Life Safety
Identified life-safety deficiencies included an inadequate smoke barrier, a sprinkler system issue, and improper use of extension cords.
NFPA 101 Life Safety Code StandardSmoke barrier walls – maintenance and integrity
NFPA 101 Life Safety Code StandardAutomatic sprinkler system maintenance and clearance
NFPA 70 National Electrical Code; NFPA 101 Life Safety Code StandardUse of extension cords and related electrical safety
09 Mar 2010Licensure
09 Mar 2010Licensure
Investigated the disaster preparedness materials and found them outdated and difficult to navigate due to misordered pages and last review dating back to 2008.
Chapter 19, Section 6Disaster Plan
05 May 2009Revisit
05 May 2009Revisit
Investigated deficiencies and confirmed corrections completed.
483.20(b)(2)(ii)
483.20(d)(3), 483.10(k)(2)
483.20(k)(3)(i)
05 May 2009Revisit
05 May 2009Revisit
Investigated a deficiency in dietetic services; the dietary manager had not completed the required certification course as of the time of the survey.
Type AState Rules and RegulationsDietetic Services
28 Apr 2009Revisit
28 Apr 2009Revisit
Verified that all previously cited deficiencies were corrected; no new deficiencies cited.
10 Mar 2009Life Safety
10 Mar 2009Life Safety
Identified multiple life-safety deficiencies including unsealed smoke barrier penetrations, disorganized emergency preparedness policies, and inadequate oversight of fire drills and equipment storage.
NFPA 101 Life Safety Code StandardSmoke barrier penetrations not sealed
NFPA 101 Life Safety Code StandardEmergency preparedness plan not organized/usable
NFPA 101 Life Safety Code StandardFire drill procedures and staff training shortcomings
NFPA 101 Life Safety Code StandardOxygen storage equipment in service corridor
NFPA 101 Life Safety Code StandardMaintenance oversight of corridor dispensers
05 Mar 2009Licensure
05 Mar 2009Licensure
Identified deficiencies in resident assessment timing, care planning updates, and nursing documentation, with several care plans not reflecting residents' current needs and some incontinence and mobility issues not properly addressed.
Type A483.20(b)(2)(ii)RESIDENT ASSESSMENT - WHEN REQUIRED
Type A483.20(k)(3)(i)COMPREHENSIVE CARE PLANS
Type A483.20(k)(3)(d)PROVIDER'S PLAN OF CORRECTION
Type A483.25(d)URINARY INCONTINENCE
Type A483.25(e)(2)RANGE OF MOTION
Type A483.75NURSING AND STAFFING
05 Mar 2009Licensure
05 Mar 2009Licensure
Investigated a deficiency in dietary supervision; the dietary manager was not certified and lacked required training to supervise dietetic services.
Section 11, Dietetic ServicesDietetic Supervision
10 Apr 2008Revisit
10 Apr 2008Revisit
Identified several deficiencies in regulatory compliance that required corrective action.
483.15(a)
483.20(d)(3), 483.10(k)(2)
483.20(k)(3)(i)
483.25(a)(3)
483.65(b)(3)
483.70(h)(4)
483.75(j)(1)
12 Mar 2008Revisit
12 Mar 2008Revisit
Found Life Safety Code deficiencies with corrections completed by 2008-03-10 and follow-up conducted, confirming steps taken.
NFPA 101 Life Safety CodeLife Safety Code deficiency (K0018)
NFPA 101 Life Safety CodeLife Safety Code deficiency (K0025)
NFPA 101 Life Safety CodeLife Safety Code deficiency (K0069)
14 Feb 2008Life Safety
14 Feb 2008Life Safety
Identified multiple life-safety deficiencies, including obstructed doors, unsealed penetrations, and failures in testing and maintaining fire alarm and safety systems.
NFPA 101 LIFE SAFETY CODE STANDARDSmoke barriers/doors and smoke compartments
NFPA 101 LIFE SAFETY CODE STANDARDSmoke barrier penetrations and fire barrier construction
NFPA 101 LIFE SAFETY CODE STANDARDFire alarm system testing
NFPA 101 LIFE SAFETY CODE STANDARDCommercial cooking facilities fire protection system testing
NFPA 101 LIFE SAFETY CODE STANDARDBattery indicator lights and maintenance testing for safety systems
NFPA 101 LIFE SAFETY CODE STANDARDFire alarm system testing and maintenance (continued)
31 Jan 2008Licensure
31 Jan 2008Licensure
Identified a deficiency in dietetic services due to the dietary manager not being a registered dietitian and delays in completing the required coursework.
Type ASection 11. Dietetic ServicesDietetic Services
31 Jan 2008Licensure
31 Jan 2008Licensure
The findings showed deficiencies in care planning, daily living activities, infection control, and environmental safety, with multiple instances where required procedures were not followed or documented.
09 May 2007Revisit
09 May 2007Revisit
Corrections completed after a post-certification revisit; multiple deficiencies were cited.
483.20, 483.20(b)
483.20(g) - (i)
483.20(k)(b)
483.25(n)
483.25(i)
483.40(b)
483.40(c)(1)-(2)
483.65(b)(3)
483.75(i)(1)
17 Apr 2007Revisit
17 Apr 2007Revisit
Found life safety code deficiencies cited; all observed issues were corrected.
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
17 Apr 2007Revisit
17 Apr 2007Revisit
Verified corrections for prior deficiencies were completed and the follow-up visit confirmed compliance.
14 Feb 2007Life Safety
14 Feb 2007Life Safety
Investigated a routine licensing survey and found multiple life-safety deficiencies related to door safety, fire drills, and backflow prevention, indicating non-compliance with federal life-safety requirements.
42 CFR 483.70(a)Life safety code – general
42 CFR 483.70(a)Fire safety – drill scheduling
NFPA 101 Life Safety Code Standard 19.3.6.3.6Backflow prevention/inspection
42 CFR 483.70(a)Fire drill records and timing
08 Feb 2007Licensure
08 Feb 2007Licensure
Found deficiencies related to TB testing/documentation and dietetic supervision, with missing or incomplete records identified during the review.
Type ASection 11. Dietetic ServicesDietetic Services
Type AState TB testing requirementsTuberculosis testing
Type AState TB testing requirementsTB testing documentation
08 Feb 2007Licensure
08 Feb 2007Licensure
The facility had multiple deficiencies related to resident assessment, care planning, daily care documentation, immunization, medical records, and infection control during the survey.
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06 Feb 2007Life Safety
06 Feb 2007Life Safety
Inspections identified multiple life-safety and electrical deficiencies, including improper use of extension cords, missing covers, and inadequate maintenance and testing of life-safety systems.
NFPA 101 Life Safety Code Standard; NFPA 70 National Electrical CodeUncovered/unguarded electrical condition near Resident room #220
NFPA 101 Life Safety Code StandardEmergency lighting system testing not performed
NFPA 101 Life Safety Code StandardIllumination of means of egress not verified by test
NFPA 101 Life Safety Code StandardMaintenance director oversight frequency
NFPA 101 LIFE SAFETY CODE STANDARDFire alarm testing and QA review documentation
NFPA 101 LIFE SAFETY CODE STANDARDContinued maintenance/testing program for life safety systems
NFPA 101 LIFE SAFETY CODE STANDARDFire safety equipment clearance and coverage (sprinkler/lighting)
02 May 2006Life Safety
02 May 2006Life Safety
Found multiple life-safety deficiencies related to door construction, smoke barriers, and exit/lighting maintenance during the investigation.
NFPA 101 Life Safety Code Standard 7.2.1.14Doors protecting corridor openings
NFPA 101 Life Safety Code StandardSmoke barriers
NFPA 101 Life Safety Code StandardLinen/closet door hardware and maintenance
NFPA 101 Life Safety Code StandardLighting/egress maintenance
NFPA 101 Life Safety Code Standard; NFPA 13 and NFPA 25 (as referenced)Sprinkler system maintenance and coverage
Investigated deficiencies in care planning, execution of mobility therapy, accident prevention, and antipsychotic drug management, with multiple noncompliances cited.
483.20(d), 483.20(k)(1)COMPREHENSIVE CARE PLANS
483.25(e)(2)RANGE OF MOTION
483.25(h)(2)ACCIDENTS
483.25(h)(2)ANTIPSYCHOTIC DRUGS
15 Nov 2005Life Safety
15 Nov 2005Life Safety
Found deficiencies in life-safety systems and emergency power: there was no sprinkler coverage under the roof, sprinkler heads showed corrosion, and the emergency generator was not properly maintained or tested.
Type ANFPA 101 Life Safety Code StandardLife Safety Code Standard
Type ANFPA 101 Life Safety Code StandardLife Safety Code Standard
Type ANFPA 110 Emergency and Standby Power SystemsEmergency Power Generator
Type ANFPA 110 Emergency and Standby Power SystemsEmergency Power Generator
04 Nov 2005Complaint
04 Nov 2005Complaint
Determined that no deficiencies were identified in the complaint investigation.
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