Rawlins Rehabilitation and Wellness

    542 16th St, Rawlins, WY 82301
    • Assisted Living
    • Memory Care
    • Skilled Nursing

    Compassionate staff helped mother thrive

    I entrusted my mother to this facility and felt reassured - the professional, friendly, and compassionate staff went above and beyond, kept me informed, and helped her recover and thrive with clean rooms, engaging activities, and attentive management. Very pleased overall; a few small tweaks would make it perfect.

    Loved one of resident
    Jul 2026

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Medication management

    Healthcare staffing

    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Transportation

    • Community operated transportation
    • Transportation arrangement

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    Reviews

    4.83·(30)

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      4.3
    • Staff

      4.4
    • Meals

      4.8
    • Amenities

      5.0
    • Value

      4.8

    Pros

    • Compassionate, attentive caregiving staff
    • Knowledgeable nursing and therapy personnel
    • Strong rehabilitation outcomes and effective therapy
    • Engaging activities and community outings
    • Clean, well-maintained facility environment
    • Home-like, welcoming atmosphere
    • Residents report comfort and satisfaction
    • Management and director praised for responsiveness

    Cons

    • Inconsistent licensed nursing coverage during admissions and transitions
    • Weak medication-management and administration controls
    • Gaps in privacy and confidentiality practices
    • Inconsistent administrative communication with families
    • Variable clinical-incident response and oversight

    Summary of reviews

    Overall impression: Reviews present a mixed picture. Many families and residents describe a supportive, home-like environment with compassionate staff, successful rehabilitation outcomes, and active programming. At the same time, a subset of reviews raises serious concerns about clinical processes and administrative communication that prospective families should clarify before admission.

    Care quality: Several accounts highlight effective therapy and successful returns to home after rehabilitation, with staff described as attentive and committed to recovery. However, there are also reports indicating failures in medication administration controls and gaps in clinical oversight for higher-risk medications. These reports suggest an operational weakness in medication safety checks and monitoring rather than a uniform pattern of care; nevertheless, they represent serious clinical-system issues that warrant direct questions about protocols and safeguards.

    Staff: Direct-care staff are frequently described as friendly, compassionate, and willing to go above and beyond. Nursing and therapy personnel receive positive comments for knowledge and helpfulness, and many reviewers said staff kept them informed about day-to-day care. Conversely, reviewers also described inconsistent licensed-nurse coverage during admissions or transitions and uneven management of clinical incidents, which can affect timeliness and reliability of clinical attention.

    Dining: Review summaries contain little specific information about dining or meal quality. There is no consistent commentary on food service in the available summaries, so prospective families should request menus, sample meal plans, and any therapeutic-diet accommodations during a tour.

    Activities and community life: Activity programming is a clear strength in the reviews. Residents and families noted engaging events and community outings (including participation in local fairs), and described residents as enjoying exhibits and social opportunities. These items point to an active social calendar that contributes to a home-like atmosphere.

    Facilities and cleanliness: The facility is described as clean and well-maintained, with a comfortable, welcoming environment that residents characterize as a "home away from home." Cleanliness and a pleasant physical environment are common positive themes.

    Management and communication: Opinions about management are mixed. Several reviewers praised the director and on-site management for responsiveness and supportive engagement. At the same time, there are complaints about administrative communication channels — including lapses in office-level communication with families and concerns about privacy/confidentiality practices. Additionally, at least one reviewer raised very serious clinical concerns, including medication-administration errors and gaps in nursing coverage; that reviewer also expressed concerns following a resident's death. These are individual but significant reports that prospective families should address directly with leadership.

    Notable patterns and guidance for families: Strengths center on direct-care staff engagement, effective therapy for rehabilitation, active programming, and a clean, home-like facility. The most significant operational risks described relate to inconsistent licensed-nurse coverage during admissions/transitions, medication-safety controls, privacy practices, and variable administrative communication. When evaluating this provider, ask specific questions about staffing ratios and licensed nurse availability, medication administration and double-check protocols (particularly for high-risk drugs), HIPAA/confidentiality procedures, and the facility's clinical-incident notification processes. Touring the unit, meeting nursing and therapy staff, and speaking with current residents or family-members can help corroborate the themes in these reviews.

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    Medicare Ratings

    3·/ 5
    • Overall

    • Health Inspection

    • Staffing

    • Quality Measures

    Ratings from the U.S. Centers for Medicare & Medicaid Services (Care Compare). View on Medicare.gov

    Location

    Map showing location of Rawlins Rehabilitation and Wellness

    Rawlins Rehabilitation and Wellness is located at 542 16th St, Rawlins, WY, 82301.

    About Rawlins Rehabilitation and Wellness

    Rawlins Rehabilitation and Wellness is dedicated to providing comprehensive care within a peaceful and welcoming environment, tailored to meet both short-term rehabilitation needs and long-term care requirements. The community is recognized for its excellence in quality care, continually striving to deliver compassionate and exceptional services for every resident. The approach at Rawlins Rehabilitation and Wellness centers on high-quality, patient-centered care, ensuring that both post-acute rehabilitation and skilled nursing services are provided in a supportive and nurturing atmosphere.

    Residents at Rawlins Rehabilitation and Wellness experience care that is guided by their unique preferences. This includes personalized meal choices, engaging daily activities, and specialized therapy services. The warm, home-like setting is carefully cultivated to make every resident feel comfortable and supported while their individual healthcare needs are met. Skilled nursing and an array of rehabilitation therapy services are at the heart of the care offered, with programs designed to help residents restore mobility, regain strength and independence, and enhance their overall well-being during recovery from illness, injury, or surgery.

    Therapies available at Rawlins Rehabilitation and Wellness include Physical Therapy, which focuses on improving strength, balance, and mobility, with the goal of reducing pain and preventing falls. Occupational Therapy helps residents reclaim daily living skills—such as dressing, grooming, and meal preparation—using adaptive tools and techniques so they can maintain as much independence as possible. Speech and Language Therapy is also offered, which supports residents in regaining effective communication, improving cognitive function, and addressing swallowing challenges, ultimately boosting confidence and quality of life.

    For those living with Alzheimer’s disease or other dementia-related conditions, Rawlins Rehabilitation and Wellness provides a safe and structured Memory Support environment. Compassionate care teams deliver stability, personalized attention, and programs crafted to enhance residents' well-being while helping to preserve their independence. Resources, education, and ongoing support are offered to family members, ensuring that loved ones are both informed and reassured about the exceptional care available.

    Additionally, the Respite Stay program at Rawlins Rehabilitation and Wellness offers an ideal temporary care solution, whether to provide relief for family caregivers, support post-hospital recovery, or allow for trial stays before making a long-term decision. Short-term stays are accompanied by skilled nursing care available around the clock, creating a safe and supportive environment where every guest receives attentive and personalized care.

    Alongside its core services, Rawlins Rehabilitation and Wellness offers a range of supplementary care options to address more complex or individualized health needs. These include wound care, IV therapy, pain management, catheter care, an enteral feeding program, access to off-site dialysis, post-hospital extended care, and arrangements for dental, vision, and audiology appointments. The focus remains on prioritizing residents’ well-being and helping them navigate care at every stage of their journey.

    Rawlins Rehabilitation and Wellness is also committed to fostering a strong and connected community, providing opportunities for both residents and staff to grow and thrive. The dedication to enhancing healthcare and strengthening relationships is evident throughout the services and environment, making it a place where high-quality care and exceptional support are woven into everyday life.

    People often ask...

    Rawlins Rehabilitation and Wellness offers assisted living, memory care, and skilled nursing.

    There are 2 photos of Rawlins Rehabilitation and Wellness on Mirador.

    The full address for this community is 542 16th St, Rawlins, WY 82301.

    No, Rawlins Rehabilitation and Wellness does not offer respite care. Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.

    Safety & Compliance

    In Wyoming, the Department of Health's Healthcare Licensing & Surveys program licenses care facilities and publishes licensure, complaint, and life-safety findings.

    License numbernh-209
    Facility typeNursing Home

    Inspection Reports

    149

    Reports

    17

    Type A Citations

    0

    Type B Citations

    53

    Complaints

    21

    Years

    12 Aug 2025Life Safety
    Found corridor separation not maintained due to removal of a library door and lack of supervised smoke detection, with inadequate direct supervision in the library space.
    • NFPA 101, 2012 Edition, 19.3.6.1(c)Corridors - Areas Open to Corridor
    07 Aug 2025Licensure
    Identified deficiencies in medication management, care planning, lift safety, and infection control.
    • CFR 483.10(e)(1); 483.12(a)(2); 483.45(c)(3)(d)(e); 483.45(d); 483.45(e)Right to be free from chemical restraints; unnecessary drugs; gradual dose reductions
    • CFR 483.21(b)(2)(i)-(iii)Care Plan Timing and Revision
    • CFR 483.25(d)(1)-(2)Free of Accident Hazards/Supervision/Devices
    • CFR 483.80(a)(1)-(2); 483.80(a)(4); 483.80(e); 483.80(f)Infection Prevention & Control
    07 Aug 2025Revisit
    Verified that all prior deficiencies were corrected and no new noncompliance was found.
    27 Jun 2025Complaint
    Investigated a discharge issue and found that a resident could not safely return after an acute care transfer; discharge planning, documentation, and return procedures were not adequately followed.
    • 42 CFR §483.15(c)(1)-(7); 42 CFR §483.15(e)(1)-(2); §483.21(c)(1)-(2)Inappropriate discharge from facilities; discharge planning and readmission requirements
    20 Feb 2025Complaint
    Determined that no deficiencies were identified during the complaint investigation. The findings showed no regulatory violations.
    18 Sept 2024Complaint
    Found no deficiencies related to the complaint investigation.
    16 Jul 2024Revisit
    Verified previous deficiencies were corrected and no new noncompliance was found.
    11 Jun 2024Revisit
    Verified no new non-compliance and determined compliance with CFR 483.90. No deficiencies were found.
    02 May 2024Complaint
    Investigated found failures in CPR adherence to advance directives, medication safety lapses, and unsafe food handling due to expired items and cleanliness issues.
    • CFR 483.24(a)(3)Cardio-Pulmonary Resuscitation (CPR)
    • CFR 483.45(f)Medication Errors
    • CFR 483.60(i)(1)(2)Food Safety - Procurement, Storage, Preparation, and Serving
    01 May 2024Life Safety
    Identified fire safety deficiencies, including a door with a self-closing device that failed to close and latch. Found sprinkler-related issues due to stored materials within 18 inches of heads in storage areas.
    • NFPA 101, 19.3.2.1; 19.3.2.1.3Doors with Self-Closing Devices
    • NFPA 101, 19.3.5.1; 9.7.5; NFPA 25, 5.2.1.2Sprinkler System - Maintenance and Testing
    03 Nov 2023Complaint
    Investigated a complaint and found no deficiencies.
    11 Oct 2023Complaint
    Investigated the complaint intake and found no deficiencies identified.
    06 Jun 2023Revisit
    Concluded compliance after revisits; all deficiencies were corrected. No new noncompliance was found.
    02 Jun 2023Revisit
    Confirmed that prior deficiencies were corrected and no new noncompliance was found.
    02 Jun 2023Revisit
    Found no deficiencies. All previous deficiencies were corrected.
    02 Jun 2023Complaint
    Investigated the complaint and found no deficiencies.
    18 May 2023Complaint
    Investigated a complaint intake and found no deficiencies identified.
    31 Mar 2023Licensure
    Multiple deficiencies were identified across safeguarding, billing notices, assessments, infection control, and dietary leadership, including improper notices to beneficiaries, risk of abuse, delayed resident assessments, and lapses in infection control.
    • CFR 483.10(g)(17)-(18)Medicaid/Medicare Coverage/Liability Notice
    • CFR 483.12(a)Free from Abuse and Neglect
    • CFR 483.12(c)Investigate/Prevent/Correct Alleged Violation
    • CFR 483.20(b)(1)-(2)Comprehensive Assessments & Timing
    • CFR 483.60(a)-(b)Qualified Dietary Staff
    • CFR 483.80(a)-(f)Infection Prevention & Control
    31 Mar 2023Licensure
    Concluded no deficiencies were found. The survey determined compliance with state requirements.
    29 Mar 2023Life Safety
    Identified multiple life-safety and emergency-preparedness deficiencies, including emergency power testing, unobstructed means of egress, hazardous area door protections, kitchen hood inspections, fire alarm maintenance, and electrical system testing.
    • 42 CFR 483.73(e)Emergency and standby power systems
    • 42 CFR 483.90Means of Egress - General
    • 42 CFR 483.90Hazardous Areas - Enclosure
    • NFPA 101; NFPA 96Cooking Facilities
    • NFPA 70; NFPA 72Fire Alarm System - Testing and Maintenance
    • NFPA 99Electrical Systems - Other
    • NFPA 99; NFPA 110Electrical Systems - Essential Electric System
    02 Mar 2023Complaint
    Found that physician visits were not performed at least every 60 days after the initial 90 days for at least one resident.
    • 42 CFR 483.30(c)(1)-(4)Physician Visits-Frequency/Timeliness/Alt
    01 Dec 2022Revisit
    Concluded that all prior deficiencies were corrected. No new noncompliance was found.
    01 Dec 2022Revisit
    Verified that prior deficiencies were corrected and found no new noncompliance. Overall, compliance with applicable regulations was confirmed.
    04 Nov 2022Complaint
    Found failures to provide transfer/discharge and bed-hold notices and inadequate monitoring of psychotropic medications for residents.
    • 42 CFR 483.15(c)(3)-(6)(8)Notice Requirements Before Transfer/Discharge
    • 42 CFR 483.15(d)(1)-(2)Bed-hold Notice Upon Transfer
    • 42 CFR 483.45(e)(1)-(5)Psychotropic Drugs
    22 Aug 2022Complaint
    Investigated a complaint and found failures to follow physician orders and monitor changes in condition for residents, leading to deterioration and emergency hospital transport for one resident and delayed assessment for another.
    • CFR 483.25Quality of care
    21 Jun 2022Revisit
    Verified that all previously cited deficiencies were corrected and the facility is back in compliance.
    26 May 2022Revisit
    Verified that prior deficiencies were corrected and no new noncompliance was found.
    28 Mar 2022Licensure
    Investigated deficiencies found in resident rights, environment, medication storage, and food safety, including care dignified delivery, dirty flooring, expired medications, and unsafe storage of food-related items.
    • §483.10(a)(1)-(2); §483.10(b)Resident Rights/Exercise of Rights
    • §483.10(i)Safe/Clean/Comfortable/Homelike Environment
    • §483.45(g); §483.45(h)(1)-(2)Label/Store Drugs and Biologicals
    • §483.60(i)(1)-(2)Food Procurement,Store/Prepare/Serve-Sanitary
    23 Mar 2022Life Safety
    Identified multiple life safety and emergency preparedness deficiencies, including missing state ombudsman contact information and numerous issues with egress doors, fire alarms, storage practices, and smoke barriers.
    • CFR 483.73(c)(2)Emergency Officials Contact Information
    • NFPA 101 19.2.2.2.1, 7.2.1.4.3.1Means of Egress - Other
    • NFPA 101 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6; 7.2.1.6.1; 7.2.1.6.3Egress Doors
    • NFPA 101 19.3.2.1, 8.4.3.5Hazardous Areas - Enclosure
    • NFPA 101 19.3.4.1, 9.6.1.3; NFPA 70; NFPA 72Fire Alarm System - Testing and Maintenance
    • NFPA 101 19.3.7.8(1), 19.3.7.9Subdivision of Building Spaces - Smoke Barrier Doors
    17 Jun 2021Revisit
    Verified no deficiencies were found and all previously identified issues were corrected.
    17 Jun 2021Revisit
    Verified that all previous deficiencies were corrected and no new noncompliance was found.
    02 Jun 2021Revisit
    Verified that previously cited deficiencies were corrected and found no new noncompliance; overall compliance with regulations was confirmed.
    02 Jun 2021Revisit
    Verified compliance after a follow-up visit; previous deficiencies were corrected and no new noncompliance found.
    01 Apr 2021Licensure
    Found that a qualified dietetic professional was not designated as the director of food and nutrition services and that there was no full-time on-site dietitian.
    • Wyoming Rules and Regulations Chapter 11 Section 11(a)(i)Dietetic Services
    01 Apr 2021Licensure
    Investigated a series of deficiencies across staffing, assessments, PASARR, nutrition, respiratory care, dementia treatment, psychotropic use, and dietary leadership.
    • 483.12(a)(3)(4)Not Employ/Engage Staff w/ Adverse Actions
    • 483.20(g)Accuracy of Assessments
    • 483.20(k)(1)-(3)PASARR Screening for MD & ID
    • 483.25(g)(1)-(3)Nutrition/Hydration Status Maintenance
    • 483.25(i)Respiratory/Tracheostomy Care and Suctioning
    • 483.40(b)(3)Treatment/Service for Dementia
    • 483.45(c)(3)-(5)Free from Unnec Psychotropic Meds/PRN Use
    • 483.60(a)-(b)Qualified Dietary Staff
    30 Mar 2021Life Safety
    Multiple fire safety and electrical code deficiencies were identified, including missing exit signage, hazardous storage, improper sprinkler and fire alarm components, and obstructed electrical equipment.
    • NFPA 101, 2012 edition, Sections 19.2.10.1; 7.10.1.1; 7.10.1.5.1Exit Signage
    • NFPA 101, 2012 edition, Sections 19.3.2.1; 19.3.5.9; 8.7.1; 19.3.5.9Hazardous Areas - Enclosure
    • NFPA 101, 2012 edition, Sections 19.3.4.1; 9.6.1.3; NFPA 70, 2011, 314.28(C)Fire Alarm System - Installation
    • NFPA 101, 2012 edition, Sections 19.3.4.1; 9.6.1.3; NFPA 72, 2010, 17.14.6Fire Alarm System - Initiation
    • NFPA 101, 2012 edition, Sections 19.3.5.1; 9.7.1.1(1); NFPA 13, 2010, Section 24.5.1Sprinkler System - Installation
    • NFPA 101, 2012 edition, Sections 19.3.5.1; 9.7.5; NFPA 25, 2011, Section 5.2.1.2Sprinkler System - Maintenance and Testing
    • NFPA 101, 2012 edition, 18.5.1.1; 19.5.1.1; 9.1.1; 9.1.2; NFPA 70, 2011, 406.6; 406.9Utilities - Gas and Electric
    • NFPA 101, 2012 edition, Sections 19.5.3; 9.4.2.2; ASME A17.3, 2008, Section 6.1.4Escalators, Dumbwaiters, and Moving Walks
    • NFPA 101, 2012 edition, Section 9.1.2; NFPA 70, 2011, Section 110.26Electrical Equipment - Other
    30 Mar 2021Life Safety
    Identified two Life Safety Code deficiencies: lack of continuous exhaust ventilation in a room and combustible storage in a mechanical space.
    • WDH Chapter 3 Section 5(b)(iv)(B); 2006 International Mechanical Code, Section 401.2, 402, 403Mech Ventilation - Continuous Exhaust
    • 2006 International Fuel and Gas Code, Section 305.2; WDH Chapter 3 Section 5(b)(iv)(B)Space for appliance ignition source free of combustible material
    24 Mar 2021Revisit
    Verified prior deficiencies were corrected and no new noncompliance was found.
    16 Feb 2021Complaint
    Found deficiencies in infection prevention and control due to staff not consistently using PPE in several areas, increasing the risk of COVID-19 transmission.
    • CFR 483.80(a)(1)(2)(4)(e)(f)Infection Prevention & Control
    21 May 2020Licensure
    Found no deficiencies identified during the focused infection control survey conducted May 19-21, 2020.
    11 Mar 2020Complaint
    Found no deficiencies.
    15 Jan 2020Complaint
    Investigated a complaint and found no deficiencies.
    08 Nov 2019Complaint
    Investigated a complaint and found no deficiencies.
    06 Aug 2019Revisit
    Verified that all previous deficiencies were corrected and no new noncompliance was found.
    27 Jun 2019Revisit
    Verified that all previously cited deficiencies were corrected and the site is back in compliance.
    27 Jun 2019Revisit
    Concluded that all previously cited deficiencies were corrected and compliance restored.
    23 May 2019Complaint
    Observed failure to provide/monitor respiratory care per orders, including an empty oxygen tank for a resident requiring oxygen and unclear tank-checking practices.
    • 483.25(i)Respiratory/Tracheostomy Care and Suctioning
    23 May 2019Licensure
    Found no deficiencies. Concluded compliance with state requirements.
    22 May 2019Life Safety
    Found failure to protect potable water due to aerators on sinks throughout the premises.
    • WDH Chapter 3 Section 5 (b)(iv)(E)Potable water protection
    22 May 2019Life Safety
    Found deficiencies in hazardous-area enclosures and gas cylinder storage that did not meet NFPA 101 Life Safety Code requirements.
    • NFPA 101, Life Safety Code: 19.3.2.1, 19.3.5.9Hazardous Areas - Enclosures
    • NFPA 101, Life Safety CodeGas Equipment - Cylinder and Container Storage
    27 Nov 2018Revisit
    Confirmed compliance with all regulations surveyed; all prior deficiencies were corrected and no new noncompliance found.
    25 Sept 2018Complaint
    Investigated a complaint and found deficiencies in PASARR/preadmission screening, including admissions before PASRR reviews and delays in completing PASRR II evaluations.
    • §483.20(k)(2)Preadmission Screening and Resident Review (PASRR) - Exceptions
    15 Jun 2018Revisit
    Concluded that previously cited deficiencies were corrected and no new noncompliance was found.
    08 Jun 2018Revisit
    Concluded the provider was in compliance with Federal requirements after a recertification survey conducted May 29–June 8, 2018.
    19 Apr 2018Complaint
    Found failures to provide written transfer and bed-hold notices to residents or their representatives, and to document rationale for PRN psychotropic medications. Also identified lack of appropriate documentation around transfers and PRN orders.
    • CFR 483.15(c)(3)-(6)Notice Before Transfer/Discharge
    • CFR 483.15(d)(1)-(2)Bed-Hold Notice Upon Transfer
    • CFR 483.45(e)(1)-(5)Psychotropic Drugs
    19 Apr 2018Licensure
    Concluded compliance with state requirements. No deficiencies were cited.
    17 Apr 2018Life Safety
    Identified several life-safety deficiencies including obstructed exits, improper labeling of fire-safety equipment, and inadequate testing/maintenance of fire protection systems, with corrective actions noted.
    • Means of egress unobstructed
    • Fire alarm panel labeling
    • Fire protection system maintenance
    • Required fire alarm components
    • Fire alarm system installation
    • Fire alarm system testing and maintenance
    • Combustible decorations
    14 Jul 2017Revisit
    Put back into compliance after a revisit survey addressed deficiencies from a May 24, 2017 health licensure survey.
    14 Jul 2017Revisit
    Investigated deficiencies from earlier health and life-safety surveys and confirmed the facility was returned to compliance after follow-up visits in June 2017.
    27 Jun 2017Revisit
    Put back into compliance after follow-up actions addressed earlier findings identified in prior surveys.
    25 May 2017Life Safety
    Determined a fire-safety deficiency due to the lack of a building-wide, supervised automatic sprinkler system.
    • NFPA 101 Life Safety Code; NFPA 13, Standard for the Installation of Sprinkler SystemsLife safety and sprinkler system installation standards
    24 May 2017Licensure
    Investigated elevated water temperatures in sinks across multiple rooms and documented deficiencies. Implemented corrective actions and ongoing monitoring to address the high temperatures.
    • Ch 11 Sec 6 (a)(iv) Physical EnvironmentPhysical Environment - Water temperature exceeding safe limits
    • Ch 11 Sec 6 (a)(iv) Physical EnvironmentCorrective action for high water temperatures
    24 May 2017Licensure
    Investigated a complaint and found multiple deficiencies related to environmental cleanliness, care planning and documentation, nutrition, staff staffing, and infection control.
    • Environmental cleanliness and safety deficiencies
    • Care planning and repairs during deep cleaning
    • False statements in resident assessments
    • MDs/assessments documentation accuracy
    • Dietary/dining documentation deficiencies
    • Nutritional care planning/documentation
    • Meal service/feeding management
    • Nursing staffing and related actions
    • Nurse staffing and posting adequacy
    • Infection control and isolation practices
    25 Aug 2016Revisit
    Found deficiencies cited under federal regulations; all corrections were completed by 08/05/2016.
    • 483.10(b)(4)
    • 483.10(b)(5) - (10), 483.10(b)(1)
    • 483.20(d)(3), 483.10(k)(2)
    • 483.25(c)
    • 483.25(k)
    • 483.25(l)
    • 483.25(m)(1)
    • 483.25(i)
    25 Aug 2016Revisit
    Verified that deficiencies previously cited were corrected.
    • 483.20(b)(2)(i)CMS 483.20(b)(2)(i)
    • 483.20(b)(2)(ii)CMS 483.20(b)(2)(ii)
    • 483.20(k)(3)(i)CMS 483.20(k)(3)(i)
    06 Jul 2016Revisit
    Found no deficiencies.
    30 Jun 2016Licensure
    Regulators found multiple deficiencies in resident care and facility operations, including gaps in care planning, documentation, and monitoring for safety and health concerns.
    19 May 2016Licensure
    The agency found deficiencies in timely assessment and care planning, including failure to complete a comprehensive resident assessment within the required period and incomplete incorporation of care needs into the care plan.
    • Type A483.20(b)(2)(i)Comprehensive Assessment
    • Type A483.20(b)(2)(ii)Care Plan (development using assessment)
    • Type A483.20(k)(3)(i)Care Plan
    19 May 2016Licensure
    Identified no state deficiencies during the licensure survey conducted May 17-19, 2016.
    17 May 2016Life Safety
    Identified life-safety deficiencies related to door locking hardware and emergency lighting, including locks that require more than one operation to open and lack of battery-powered emergency lighting near the generator area.
    • 2000 NFPA 101, Sections 19.2.2.2.1 and 7.2.1.5.4LIFE SAFETY CODE STANDARD
    • NFPA 101 Life Safety Code Standard, Exit Access (Sections 7.1, 19.2.2.2.1 and 7.2.1.5.4)EXIT ACCESS
    30 Jun 2015Revisit
    Verified corrections of deficiencies identified earlier; corrective actions were completed on 05/08/2015 and 06/15/2015.
    25 Jun 2015Revisit
    Investigated and confirmed corrections were completed for previously identified deficiencies during a post-certification revisit.
    04 Jun 2015Revisit
    Found no deficiencies. No violations were cited.
    23 Apr 2015Licensure
    Identified deficiencies in safety and cleanliness, including inadequate housekeeping/maintenance, resident care for well-being, and infection control.
    • Safe/Clean/Comfortable Environment
    • Housekeeping and Maintenance Services
    • Provide Care/Services for Highest Well Being
    • Infection Control - Systemic Changes
    • Infection Control - Infection Control/Prevention
    23 Apr 2015Licensure
    Found no deficiencies; determined compliance with state requirements.
    20 Apr 2015Life Safety
    Identified a deficiency in exit access; door locks in administration areas hindered exits from being readily accessible.
    • NFPA 101 Life Safety Code Standard, 2000 edition, Sections 7.2.1.5.1 and 7.2.1.4.5NFPA 101 Life Safety Code Standard
    20 Apr 2015Life Safety
    Investigated a complaint and found deficiencies in maintaining continuous mechanical exhaust ventilation in bath/tub areas and in plumbing systems, including eyewash station tempering valves.
    • IMC Life Safety - Intl Mechanical CodeInternational Mechanical Code - Life Safety
    • IPC Life Safety - Intl Plumbing CodeInternational Plumbing Code - Life Safety
    21 Jan 2015Complaint
    Investigated a complaint; found no deficiencies identified.
    29 Aug 2014Revisit
    Investigated a prior complaint and confirmed corrections were completed.
    03 Jul 2014Revisit
    Investigated a follow-up visit and identified multiple deficiencies indicating noncompliance with federal care standards.
    • 483.13
    • 483.15(g)(1)
    • 483.20(k)(3)(i)
    • 483.20(b)(1)
    • 483.40(b)
    • 483.75(i)(1)
    10 Apr 2014Complaint
    The facility failed to provide medically related social services by not evaluating a resident’s increasing signs of depression.
    • 483.15(g)(1)Provision of Medically Related Social Services
    10 Apr 2014Complaint
    Found deficiencies in the provision of medically-related social services and in resident assessment processes.
    • 483.15(g)(1)Provision of Medically Related Social Services
    10 Apr 2014Life Safety
    Identified multiple life-safety deficiencies, including electrical wiring concerns, improvised power tap use, and inadequate sprinkler coverage.
    • NFPA 101 LIFE SAFETY CODE STANDARDLIFE SAFETY CODE STANDARD
    • NFPA 101 LIFE SAFETY CODE STANDARDLIFE SAFETY CODE STANDARD
    • NFPA 101 LIFE SAFETY CODE STANDARDLIFE SAFETY CODE STANDARD
    • NFPA 101 LIFE SAFETY CODE STANDARDLIFE SAFETY CODE STANDARD
    31 May 2013Licensure
    Identified deficiencies in governance and administration oversight, including lack of a full-time, on-site licensed administrator.
    • Organization and Administration
    03 Apr 2013Revisit
    Investigated follow-up on a prior deficiency and verified some corrective actions were completed, with uncorrected deficiencies remaining.
    31 Jan 2013Licensure
    Found deficiencies in resident care and documentation, including inadequate pain management, incomplete comprehensive assessments after significant changes, and deficient cross-referencing of corrective actions.
    • Summary statement of deficiencies (each deficiency must be preceded by full regulatory or LSC identifying information)
    • COMPREHENSIVE ASSESSMENT AFTER SIGNIFICANT CHANGE
    • PLAN OF CORRECTION CROSS-REFERENCING
    • PROVIDE CARE/ SERVICES FOR HIGHER WELL-BEING
    31 Jan 2013Licensure
    Found no deficiencies. The survey concluded the facility met state requirements.
    30 Jan 2013Life Safety
    Investigated a complaint and found deficiencies related to life-safety and electrical safety, including prohibited portable heating devices and issues with electrical code compliance.
    • NFPA 101 Life Safety Code StandardPortable space heating devices
    • NFPA 70, National Electrical CodeElectrical safety compliance (NFPA 70)
    • Plan of correction oversight
    30 Jan 2013Revisit
    Identified prior deficiencies with uncorrected items and a follow-up was conducted to verify corrections.
    11 Sept 2012Complaint
    Investigated a complaint and found no deficiencies.
    08 May 2012Revisit
    Identified multiple regulatory deficiencies and proceeded with corrective actions; all identified items show corrections completed.
    • 483.10(b)(4)Participation regulation deficiency
    • 483.13(c)(1)(ii)-(iii), (c)(2)-(4)Resident rights/regulatory requirement
    • 483.20(d), 483.20(k)(1)Staffing and assignment requirements
    • 483.40(c)(1)-(2)Admission, Transfer, and Discharge requirements
    • 483.75(c)(1)Quality of care and services
    • 483.75(i)(5)-(7)Administration and governance requirements
    • 483.25(d)Licensing and certification standards
    • 483.60(b)(1)Facility requirements for residents
    • 483.65Other regulatory requirements
    • 483.75(d)(3)Specific subdivision of care requirements
    • 483.75(d)(2)Specific subdivision of care requirements
    23 Apr 2012Revisit
    Investigated a complaint and corrected multiple life-safety deficiencies; follow-up confirmed corrections were completed.
    01 Mar 2012Licensure
    An investigation identified deficiencies involving responses to alleged violations, resident involvement in planning care, and medication management.
    • Type AContinuation of investigation and protection against further abuse
    • Type AResident rights to participate in care planning
    • Type AMedication storage and administration procedures
    01 Mar 2012Licensure
    Investigated a state licensure survey and found no deficiencies.
    27 Feb 2012Life Safety
    Investigated a complaint and found multiple life-safety deficiencies and maintenance issues during the survey.
    15 Feb 2012Revisit
    Verified that prior deficiencies were corrected; no deficiencies were cited.
    22 Dec 2011Complaint
    Investigation found deficiencies in resident assessment and care planning, with multiple items indicating inadequate development and ongoing updates of individualized care plans for residents.
    • 42 CFR 483.20Comprehensive Resident Assessment/Care Plan
    22 Apr 2011Revisit
    Verified corrections were completed for deficiencies identified earlier and found substantial compliance.
    • 483.20(g) - (i)
    • 483.20(k)(3)(iii)
    • 483.25
    18 Apr 2011Revisit
    Identified Life Safety Code deficiencies with uncorrected items noted at follow-up.
    • NFPA 101 Life Safety CodeLife Safety Code deficiency (K0062)
    • NFPA 101 Life Safety CodeLife Safety Code deficiency (K0038)
    • NFPA 101 Life Safety CodeLife Safety Code deficiency (K0147)
    25 Feb 2011Licensure
    Found deficiencies in MDS documentation and care planning, and failures to follow wound care and weight-management orders for residents.
    • Deficiencies related to MDS accuracy and ARD
    • Services by qualified persons per plan of care
    • Provide care/services for highest well being
    25 Feb 2011Licensure
    Concluded compliance with state requirements.
    23 Feb 2011Life Safety
    Investigated life-safety concerns with multiple deficiencies observed in exits, egress conditions, and storage practices.
    • NFPA 101 Life Safety Code StandardLife Safety Code Standard
    • NFPA 101 Life Safety Code StandardLife Safety Code Standard
    • NFPA 101 Life Safety Code StandardLife Safety Code Standard
    • NFPA 101 Life Safety Code StandardLife Safety Code Standard
    • NFPA 101 Life Safety Code StandardLife Safety Code Standard
    01 Nov 2010Revisit
    Investigated deficiencies were corrected. Follow-up confirmed corrections completed.
    • 483.10(i)(1)
    • 483.15(c)(6)
    • 483.15(h)(2)
    • 483.25(i)
    • 483.65
    • 483.75(b)(1)
    12 Aug 2010Licensure
    Determined that the minimum qualifications for the dietary manager were not met, based on staff interviews and enrollment records.
    • Section 11. Dietetic ServicesDietetic Services
    12 Aug 2010Complaint
    Identified deficiencies in grievance handling, infection control, housekeeping/maintenance, and quality-assurance planning during the licensing process.
    • Type A483.15(c)(6)LISTEN/ACT ON GROUP GRIEVANCE/RECOMMENDATION
    • 483.25(i)INFECTION CONTROL, PREVENT SPREAD, LINENS
    • 483.75(h)(2)HOUSEKEEPING & MAINTENANCE SERVICES
    • 483.75COMMITTEE-MEMBERSHIP/MEET QUARTERLY/PLANS
    11 Aug 2010Revisit
    Concluded corrections were completed for life-safety deficiencies after a revisit. Follow-up confirmed compliance.
    • LSC; NFPA 101Life Safety Code deficiency
    • LSC; NFPA 101Life Safety Code deficiency
    • LSC; NFPA 101Life Safety Code deficiency
    11 Aug 2010Life Safety
    Findings showed life-safety deficiencies related to exit door hardware, locked gates, sprinkler head placement, and emergency lighting.
    • NFPA 101 LIFE SAFETY CODE STANDARDLIFE SAFETY CODE STANDARD
    • NFPA 101 LIFE SAFETY CODE STANDARDLIFE SAFETY CODE STANDARD
    • NFPA 101 LIFE SAFETY CODE STANDARDLIFE SAFETY CODE STANDARD
    27 Apr 2010Revisit
    Investigated a prior deficiency finding and confirmed corrective actions were completed for life-safety code issues. Follow-up indicated corrections were made with no uncorrected deficiencies remaining.
    • NFPA 101 / Life Safety CodeLife Safety Code deficiency - K0029
    • NFPA 101 / Life Safety CodeLife Safety Code deficiency - K0050
    • NFPA 101 / Life Safety CodeLife Safety Code deficiency - K0062
    • NFPA 101 / Life Safety CodeLife Safety Code deficiency - K0147
    15 Apr 2010Revisit
    Confirmed corrections completed for previously cited deficiencies.
    25 Feb 2010Licensure
    Found no deficiencies.
    25 Feb 2010Licensure
    Investigated findings included deficiencies in care planning, resident rights, and facility operations, with corrective actions required.
    23 Feb 2010Life Safety
    Identified several life-safety deficiencies, including issues with sprinkler system maintenance, smoke-resistance of walls, and improper fire drill practices.
    • NFPA 101 LIFE SAFETY CODE STANDARDSprinkler system maintenance and smoke-resistance
    • NFPA 101 LIFE SAFETY CODE STANDARDFire drills and alarm response
    • NFPA 101 LIFE SAFETY CODE STANDARDSprinkler heads corrosion and replacement
    • NFPA 101 LIFE SAFETY CODE STANDARDStaff training on fire response duties
    01 Oct 2009Revisit
    Investigated and verified that previously cited deficiencies were corrected; corrections were completed by 08/10/2009.
    01 Oct 2009Revisit
    Verified corrections from a prior finding were completed with no new deficiencies cited.
    10 Sept 2009Revisit
    Follow-up documented corrections for deficiencies cited previously; multiple items completed by the specified date.
    • 483.15(a)
    • 483.20, 483.20(b)
    • 483.20(k)(3)(i)
    • 483.20(c)(1)-(2)
    • 483.60(c)
    • 483.25(a)(3)
    • 483.75(i)(1)
    13 Aug 2009Life Safety
    Investigated a safety concern and found multiple life-safety deficiencies, including an incomplete sprinkler system and unsafe electrical 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
    09 Jul 2009Licensure
    Investigated found deficiencies in dining dignity and resident assessments, indicating problems with how care and meals were managed and documented.
    • Type A483.15(a)Dignity
    • 483.20(k)(3)(i)Resident Assessment; Comprehensive Care Plans
    09 Jul 2009Licensure
    Found no deficiencies. The survey concluded compliance with state requirements.
    08 Jul 2009Life Safety
    The inspection found life-safety and electrical deficiencies, including issues with smoke partitions, improper use of portable heaters, and electrical wiring problems.
    • NFPA 101 LIFE SAFETY CODE STANDARDSmoke partitions not maintained as required
    • NFPA 101 LIFE SAFETY CODE STANDARDPortable space heaters not allowed or not properly controlled
    • NFPA 70 NATIONAL ELECTRICAL CODEElectrical wiring/equipment not in compliance with NEC
    18 Feb 2009Revisit
    Investigated and found deficiencies; follow-up confirmed corrections completed.
    • 483.75(i)(1)
    • 483.75(o)(1)
    • 483.25(h/i)
    • 483.35(d)(1)
    • 483.35(i)
    • 483.65(c)
    18 Feb 2009Revisit
    Found no deficiencies. The review did not identify any violations.
    15 Jan 2009Revisit
    Identified Life Safety Code deficiencies and noted corrections completed for the cited items.
    • LSC K0038Life Safety Code deficiency
    • LSC K0052Life Safety Code deficiency
    • LSC K0062Life Safety Code deficiency
    11 Dec 2008Licensure
    Identified noncompliance with TB testing requirements; four new hires had tuberculin test results not read before starting resident contact.
    • Rules and Regulations for Program Administration of Nursing Care Facilities, Chapter 11, Section 5State Rules and Regulations
    10 Dec 2008Life Safety
    Identified life-safety deficiencies, including failure to properly test the fire alarm system and inadequate exit access/egress.
    • NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code – Fire alarm system requirements
    • NFPA 101 LIFE SAFETY CODE STANDARDExit access and egress path
    • NFPA 101 LIFE SAFETY CODE STANDARDLife safety – door and access safety adaptations
    10 Dec 2008Complaint
    Found deficiencies in residents' ability to self-administer medications, use of restraints, and maintenance of dignity for residents.
    • 483.10(n)Self Administration of Drugs
    • 483.13(a)PHYSICAL RESTRAINTS
    • 483.15(a)DIGNITY
    16 Nov 2007Revisit
    Investigated and found no deficiencies.
    20 Sept 2007Complaint
    Identified a deficiency requiring immediate notification of changes in a resident's condition to residents, physicians, and family when incidents occur.
    • Notification of changes
    24 Jan 2007Complaint
    Investigated a complaint; found no deficiencies.
    11 Jan 2007Revisit
    Identified deficiencies were corrected by 12/19/2006, and a revisit was conducted on 2007-01-11 to confirm compliance.
    30 Nov 2006Licensure
    Found deficiencies in residents' voting rights, notification of changes, access to survey results, mail handling, medication self-administration safety, dignity/privacy, and completeness of resident assessments and activities.
    • 483.10(a)(1)EXERCISE OF RIGHTS
    • NOTIFICATION OF CHANGES
    • EXAMINATION OF SURVEY RESULTS
    • MAIL
    • SELF ADMINISTRATION OF DRUGS
    • DIGNITY
    • COMPREHENSIVE ASSESSMENTS
    • ACTIVITIES
    30 Nov 2006Licensure
    Found deficiencies in TB testing documentation for several staff, with missing proof of negative TB tests before resident contact and incomplete health screening records.
    • State Rules and RegulationsState Rules and Regulations
    • State Rules and RegulationsState Standards
    • State Rules and RegulationsRules and Regulations for Program Administration of Nursing Care Facilities
    • State Rules and RegulationsSection 5. Organization and Administration
    27 Nov 2006Revisit
    Verified corrections completed for previously cited deficiencies and confirmed continued compliance.
    15 Nov 2006Life Safety
    Identified violations related to life safety features, including corridor doors not sealing properly and related fire-safety deficiencies.
    • Type A42 CFR 483.70(a); NFPA 101 Life Safety Code 19.1.6.4; 3.3.185Initial Comments
    07 Sept 2006Complaint
    Cited deficiencies in urinary incontinence care, oxygen administration, and medical records; observed failures to provide appropriate care and maintain documentation.
    • 483.25(d)URINARY INCONTINENCE
    • 483.75(b)ADMINISTRATION
    • 483.75(i)(1)CLINICAL RECORDS
    13 Jul 2006Complaint
    Investigated a complaint and found no deficiencies identified.
    05 Jul 2006Revisit
    Identified multiple deficiencies during the revisit and noted noncompliance with several CMS requirements.
    • 483.20(k)(3)(ii)
    • 483.25(e)(2)
    • 483.25(b)(2)
    • 483.25(c)
    • 483.65(a)
    • 483.65(b)(2)
    • 483.65(b)(3)
    • 483.70
    • 483.70(h)
    • 483.75(i)(1)
    • 483.60(c)(1)
    • 483.60(e)
    18 Jan 2006Complaint
    Investigated a complaint and found no deficiencies.
    23 Nov 2005Revisit
    Investigated a follow-up and cited multiple regulatory deficiencies with specified codes.
    • 483.15(c)(1), 483.70(c)(1)Regulatory requirements (general)
    • 483.20, 483.20(b)Admission/transfer/discharge requirements
    • 483.20(d), 483.20(k)(1)Resident rights and protections
    • 483.25(a)(3)Quality of care/Plan of correction
    • 483.25(d)Care planning and service delivery
    • 483.65(b)(3)Facility operations/safety standards
    • 483.25(a)Resident rights and protections
    • 483.45(a)Departmental obligations/safe operation
    • 483.65(b)(3)Additional safety/rights provision
    14 Nov 2005Revisit
    Verified corrections completed for all previously identified deficiencies; follow-up concluded.
    06 Oct 2005Licensure
    Identified deficiencies in resident assessment, accommodation of needs, activities of daily living, infection control, and rehabilitative services.
    • 483.20(g)-(j)RESIDENT ASSESSMENT
    • 483.15(e)(1), 483.70(c)(1), 483.70(d)(2)ACCOMMODATION OF NEEDS
    • 483.25(d)SUMMARY STATEMENT OF DEFICIENCIES
    • 483.25(d)URINARY INCONTINENCE
    • 483.65(b)(3)PREVENTING SPREAD OF INFECTION
    • 483.45(a)SPECIALIZED REHABILITATIVE SERVICES
    20 Sept 2005Life Safety
    Identified deficiencies related to oxygen storage signage and NFPA 101 life-safety code requirements; no-smoking signs were missing at oxygen storage closets.
    • NFPA 101 Life Safety Code StandardNFPA 101 Life Safety Code Standard
    • NFPA 101 Life Safety Code Standard; NFPA 99 Section 8.6.4.2NFPA 101 Life Safety Code Standard
    • NFPA 101 Life Safety Code Standard; NFPA 99 Section 8.6.4.2NFPA 101 Life Safety Code Standard
    31 Aug 2005Complaint
    Investigated deficiencies in care and nursing services, including inadequate toileting and perineal care, insufficient staffing, and gaps in resident care planning and execution.
    • Type A483.25(a)(1)–(a)(3)Quality of Care
    • Type A483.25(a)(3)Quality of Care
    • Type A483.25(a)(1) & (2)Nursing Services
    • Type A483.30Nursing Services
    31 Aug 2005Revisit
    Found a deficiency cited under federal regulations. The correction was completed.
    • 483.25(d)(2)
    05 Aug 2005Complaint
    Investigated violations regarding inadequate nursing staff and quality of care, with observations of insufficient care and inappropriate care procedures.
    • Type ANursing services
    • Quality of care
    • Nursing staff adequacy
    05 Aug 2005Revisit
    Investigated deficiencies in care quality, including improper perineal care and inadequate continence management observed during the review.
    • 483.25Quality of Care
    • 483.25(a)(3)
    • 483.30(a)(1)&(2)
    03 Jun 2005Complaint
    The investigation found deficiencies in care quality and nursing services, including inadequate hygiene and toileting care and insufficient staffing to meet residents' needs.
    • Type A483.25(a)(3)Quality of care
    • Type ANursing services
    • Type ANursing services
    13 Apr 2005Revisit
    Identified deficiencies were corrected by the revisit date. Three deficiencies were addressed and closed.
    • 483.20(d)
    • 483.25(h)(2)
    • 483.75(j)
    13 Apr 2005Complaint
    Found no deficiencies identified in the complaint survey conducted April 12-13, 2005.
    10 Mar 2005Complaint
    Identified deficiencies in resident assessment, falls prevention, and administration. The facility failed to develop a comprehensive care plan for a resident with a history of falls and did not provide adequate supervision or timely services.
    • 483.20(k)Resident Assessment
    • 483.25(h)(2)Quality of Care
    • 483.75(i)Administration

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