I had a loving, personal experience at Thermopolis Rehabilitation and Wellness. Director Robin and the wonderful, hardworking team provided amazing, tireless care with genuine hearts and helped my family tremendously. I highly recommend them.
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
2.84·(19)
Overall rating
5
4
3
2
1
Care
4.3
Staff
3.5
Meals
2.8
Amenities
2.0
Value
2.0
Pros
Compassionate direct-care staff
Staff who go above and beyond
Supportive admissions coordination
Visible director-level engagement
Attentive nursing and therapy care
Pleasant dining/kitchen area
Family-centered assistance
Cons
Inconsistent staffing levels
Maintenance and facility-upkeep deficiencies
Cleanliness and sanitation concerns in common and memory-care areas
Inconsistent or unprofessional staff conduct and communication
Limited engagement and recreational offerings in the memory unit
High cost relative to facility condition
Summary of reviews
Reviews indicate a facility with a clear strength in hands-on caregiving: many families praised direct-care staff for being compassionate, hardworking, and willing to go "above and beyond," and some accounts singled out effective nursing and therapy support. Admissions coordination and leadership visibility were also described positively by multiple families, and the dining/kitchen area received favorable mentions. These elements suggest that clinical care and certain administrative touchpoints can be strong points of the facility.
At the same time, there is a consistent pattern of operational concerns. Several reviewers described understaffing or inconsistent staffing levels, which they linked to variable responsiveness and communication. There are repeated notes about maintenance and building condition — peeling paint, sparse décor, and a generally worn appearance — which contribute to sanitation and cleanliness concerns in some common and memory-care areas. Reviewers also expressed that parts of the memory-care wing feel institutional and restrictive rather than homelike.
Staff conduct and communication present a mixed picture: while many families described respectful and caring interactions, others described lapses in professionalism, unresponsiveness, or problematic tone from some staff members. There is at least one allegation of inappropriate conduct by an individual staff member; reviewers emphasized concerns about behavior when staff are not visibly supervised. In addition, some families reported difficulty obtaining desired room changes or clear explanations of policies, which suggests rigid room-assignment or grievance processes.
Activity and engagement in the memory-care unit emerged as a specific weakness: observers reported limited décor, absence of communal TV or entertainment in some memory areas, and a loud, sparse environment that reduced perceived resident engagement. Financially, reviewers characterized the facility as relatively expensive and questioned whether the cost aligns with the physical condition and services provided.
For prospective residents and families: the facility appears to deliver strong personal care in many cases, supported by committed staff and visible leadership, but also shows facility-level gaps in upkeep, staffing consistency, environment in the memory unit, and some aspects of communication and policy flexibility. When evaluating this facility, request current staffing ratios, a tour of the memory unit during active hours, documentation of maintenance and cleaning schedules, clarification of room-assignment and complaint processes, and references from recent families to balance the positive caregiving reports against the operational concerns.
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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
Thermopolis Rehabilitation and Wellness is located at 1210 Canyon Hills Rd, Thermopolis, WY, 82443.
About Thermopolis Rehabilitation and Wellness
Thermopolis Rehabilitation and Wellness sits at 1210 Canyon Hills Road and works as a skilled nursing facility with 60 certified beds, usually caring for about 40 residents each day, and it belongs to a for-profit corporation managed by Evergreen and affiliated with Empres, offering both short-term rehabilitation for people coming out of the hospital and long-term care for those who are frail and need daily help. The staff handles everything from physical, occupational, and speech therapy to palliative care, memory care, hospice, and person-centered support, and they do this with a focus on making each resident's life as good as it can be, always trying to find what works best for each person. You'll find plenty of wellness programs, activities, and social gatherings to help keep folks involved, plus secure support housing units, while the community aims to create a welcoming and active atmosphere that encourages everyone to join in and participate when they're able. The staff delivers a range of skilled services, including wound care, medication help, and specialized doctor-led programs, and therapy services are all on site, so residents can work on recovery without having to travel out of the building, which really makes things easier. The staff tries to be compassionate and attentive, though it helps to know the nurse turnover rate stands at 84.6%, higher than the state average, and the nurse staffing averages 3.43 hours per resident per day, falling short of the state's average of 3.9, which might be something to consider. Reports from health inspections have shown infection control deficiencies, including issues with vaccination policy, but the facility does have infection control procedures for flu and pneumonia shots in place. Thermopolis Rehabilitation and Wellness holds a special focus facility designation, which means it's been noted for some serious quality issues in the past and gets extra oversight, though it isn't formally flagged by the government, so people should check the inspection history for a clear picture. Residents get access to a broad mix of rehabilitation and wellness services, covering recovery and long-term support, including help tailored to individual needs, always aiming to keep people as healthy and comfortable as possible.
People often ask...
Thermopolis Rehabilitation and Wellness offers assisted living, memory care, and skilled nursing.
There are 1 photos of Thermopolis Rehabilitation and Wellness on Mirador.
The full address for this community is 1210 Canyon Hills Rd, Thermopolis, WY 82443.
No, Thermopolis 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 number
nh-216
Facility type
Nursing Home
Inspection Reports
132
Reports
13
Type A Citations
0
Type B Citations
64
Complaints
21
Years
09 Sept 2025Revisit
09 Sept 2025Revisit
Verified that prior deficiencies were corrected and no new noncompliance was found.
07 Jul 2025Complaint
07 Jul 2025Complaint
Investigated a complaint and found deficiencies in the timeliness and processing of diagnostic imaging services for a resident with a left hip prosthesis, including delays obtaining a left hip X-ray and related transportation issues.
§483.21(b)(3)(i)Comprehensive Care Plans
§483.50(b)(1)(i)(ii)Radiology and other diagnostic services
06 Aug 2024Revisit
06 Aug 2024Revisit
Verified that all previous deficiencies were corrected and no new noncompliance was found.
05 Aug 2024Revisit
05 Aug 2024Revisit
Found no deficiencies.
17 Jul 2024Complaint
17 Jul 2024Complaint
Found no deficiencies identified during the complaint investigation.
27 Jun 2024Licensure
27 Jun 2024Licensure
Investigated found that one resident was not offered pneumococcal vaccination per CDC recommendations, and related education/documentation were not provided.
§483.80(d)Influenza and pneumococcal immunizations
26 Jun 2024Life Safety
26 Jun 2024Life Safety
Identified multiple life-safety deficiencies, including blocked exterior egress, improper sprinkler system maintenance, inadequate fire drills, and missing electrical system testing.
NFPA 101 19.2.1, 7.1.10.1Means of egress obstruction
NFPA 25 5.2.2.2 (2011)Sprinkler System - Maintenance and Testing
NFPA 101 19.7.1.4 through 19.7.1.7Fire Drills
NFPA 99 6.3.4.1, 6.3.3.2Electrical Systems - Annual inspection/testing of non-hospital grade receptacles
NFPA 99 6.4.4, 6.5.4, 6.6.4; NFPA 110 8.4; 8.3.7.1; 8.4.2Electrical essential system - testing and maintenance of emergency generator
06 Mar 2024Complaint
06 Mar 2024Complaint
Investigated a resident abuse allegation and found the facility failed to protect the resident from verbal abuse and to properly investigate the incident, with an initial immediate jeopardy that was later resolved.
483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
Verified that previously identified deficiencies were corrected and no new noncompliance was found.
22 Aug 2023Complaint
22 Aug 2023Complaint
Investigated a complaint alleging resident-to-resident physical abuse; found that one resident was struck by another, resulting in facial bruising.
CFR 483.12(a)(1)Free from Abuse and Neglect
21 Jul 2023Revisit
21 Jul 2023Revisit
Found no deficiencies. A follow-up visit showed prior issues corrected.
20 Jun 2023Complaint
20 Jun 2023Complaint
Found no deficiencies related to the complaint investigation. The survey occurred 2023-06-19 through 2023-06-20.
01 Jun 2023Revisit
01 Jun 2023Revisit
Found no deficiencies. Follow-up confirmed continued compliance.
20 Apr 2023Licensure
20 Apr 2023Licensure
Found violations related to transfer/discharge notices, ostomy care, psychotropic medication management, and storage/expiration of medications.
CFR 483.15(c)(3)-(6)(8)Notice Requirements Before Transfer/Discharge
CFR 483.25(f)Colostomy, Urostomy, or Ileostomy Care
CFR 483.45(e)Free from Unnecessary Psychotropic Meds/PRN Use
CFR 483.45(g)-(h)Label/Store Drugs and Biologicals
20 Apr 2023Licensure
20 Apr 2023Licensure
Concluded that the provider was in compliance with State requirements.
18 Apr 2023Life Safety
18 Apr 2023Life Safety
Found multiple deficiencies in emergency preparedness and life-safety systems, including failures to test emergency plans and maintain critical safety equipment. Observed incomplete drills, obstructed egress, and inadequate maintenance across multiple systems.
42 CFR 483.73(d)(2)Emergency Testing Requirements
NFPA 101 19.2.3.4(5)Aisle, Corridor, or Ramp Width
NFPA 101 9.6.1.3, 9.6.1.5; NFPA 70; NFPA 72Fire Alarm System - Testing and Maintenance
NFPA 101 19.3.5.1; NFPA 25 5.3.1.1.1; 5.3.1.1.1.6Sprinkler System-Maintenance and Testing
NFPA 101 19.3.5.5.12; 9.7.4.1; NFPA 10 7.2.1Portable Fire Extinguishers
NFPA 101 19.7.1.6Fire Drills
NFPA 99 6.3.4.1.3; 6.3.3.2; NFPA 110 8.3.7.1Electrical Systems-Maintenance and Testing
NFPA 99 6.4.1.1.6.1; NFPA 110 8.4.1Electrical Systems-Essential Electric System
17 Apr 2023Revisit
17 Apr 2023Revisit
Verified prior deficiencies were corrected and no new noncompliance was found. All regulations surveyed were in compliance.
10 Mar 2023Complaint
10 Mar 2023Complaint
Investigated abuse/neglect and quality-of-care concerns; found failures in protecting residents from harm and in medication administration, including degraded catheter care and use of a THC-containing ointment without orders.
CFR 483.12(a)(1)Free from Abuse, Neglect, and Exploitation
CFR 483.25Quality of Care
07 Mar 2023Revisit
07 Mar 2023Revisit
Found no deficiencies. Prior issues were corrected, and no new noncompliance was found.
07 Mar 2023Revisit
07 Mar 2023Revisit
Verified that previously cited deficiencies were corrected and found no new noncompliance.
13 Jan 2023Complaint
13 Jan 2023Complaint
Found deficiencies related to resident safety, emergency care response, and hospital transfer planning.
Ch 11 Sec 6 (a)(i)Physical Environment
Ch 11 Sec 8 (b)(i)Emergency Care of Residents
Ch 11 Sec 18 (a)Transfer Agreement
13 Jan 2023Complaint
13 Jan 2023Complaint
Investigated findings identified neglect-related failures, including burns from an exposed heat source, delays in burn-center transfer, and missing hospital transfer agreements, along with staffing and assessment deficiencies.
483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
483.25(d)(1)-(2)Accidents; environment free of hazards; supervision
483.70(e)(1)-(3)Facility assessment
483.70(j)(1)-(2)Transfer agreement
30 Aug 2022Revisit
30 Aug 2022Revisit
Found no deficiencies. All previous deficiencies were corrected and no new noncompliance was found.
09 Aug 2022Complaint
09 Aug 2022Complaint
Investigated a complaint and found no deficiencies identified.
18 May 2022Revisit
18 May 2022Revisit
Verified no deficiencies; all prior deficiencies were corrected.
31 Mar 2022Licensure
31 Mar 2022Licensure
Investigation found multiple deficiencies across environment, care planning, staffing postings, antibiotic stewardship, psychotropic use, kitchen sanitation, and assessment accuracy.
CFR 483.10(i)Safe/clean/homelike environment
CFR 483.21(b)Comprehensive care plans
CFR 483.35(g)(1)-(4)Nurse Staffing Information
CFR 483.45(e)Psychotropic Drugs
CFR 483.60(i)Food safety requirements
CFR 483.80(a)(3)Infection prevention and control program; Antibiotic stewardship
CFR 483.20(g)Accuracy of Assessments
31 Mar 2022Licensure
31 Mar 2022Licensure
Determined in compliance with State requirements following a licensure survey.
30 Mar 2022Life Safety
30 Mar 2022Life Safety
Investigated life safety and egress deficiencies, including egress door hardware, corridor widths, cooking facility protections, sprinkler maintenance, smoke barrier doors, door inspections, and power-strip use in resident areas.
NFPA 101 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6; Special locking arrangementsEgress doors with special locking arrangements
NFPA 101 19.2.3.4, 19.2.3.5Aisle, Corridor, or Ramp Width
NFPA 101 10.2.3.6, 10.2.4; NFPA 99 10.2.3.6; 400-8 (NFPA 70), 590.3(D)Electrical Equipment - Power Cords and Extension Cords
01 Jul 2021Revisit
01 Jul 2021Revisit
Verified all prior deficiencies were corrected and no new noncompliance was found.
29 Apr 2021Life Safety
29 Apr 2021Life Safety
Found deficiencies in hazardous area enclosure and sprinkler installation. Observed combustible storage in a hazardous area, openings around sprinkler heads, and built-in closets lacking sprinkler coverage.
NFPA 101 19.3.2.1.3; 8.4; 19.3.5.9Hazardous Areas - Enclosure
NFPA 101 8.1.1(3); 8.1.1(1); NFPA 13Sprinkler System - Installation
28 Apr 2021Licensure
28 Apr 2021Licensure
Identified deficiencies in discharge planning, restorative/ADL maintenance, RN staffing, and psychotropic medication monitoring.
CFR 483.21Discharge Planning
CFR 483.24Activities of Daily Living (ADLs)/Maintenance
CFR 483.35RN Coverage
CFR 483.45(e)Psychotropic Drugs
28 Apr 2021Licensure
28 Apr 2021Licensure
Found no deficiencies. The survey concluded compliance with state requirements.
16 Feb 2021Complaint
16 Feb 2021Complaint
Found no deficiencies identified during the focused infection control and complaint review.
21 Apr 2020Licensure
21 Apr 2020Licensure
Identified no deficiencies in the COVID-19 focused infection control survey conducted on April 21, 2020.
15 Aug 2019Revisit
15 Aug 2019Revisit
Concluded that prior deficiencies were corrected and no new noncompliance was found, indicating overall regulatory compliance.
09 Jul 2019Revisit
09 Jul 2019Revisit
Verified that all prior deficiencies were corrected and no new noncompliance was found.
24 May 2019Life Safety
24 May 2019Life Safety
Found deficiencies in life-safety systems and electrical infrastructure, including sprinkler/fire-alarm maintenance, fire drills, and generator/emergency lighting issues.
NFPA 101; NFPA 72Fire Alarm System - Testing and Maintenance
NFPA 13Sprinkler System - Installation
NFPA 101Fire Drills
NFPA 110; NFPA 101Electrical Systems - Essential Electric
NFPA 101 19.3.2.1.3Hazardous Areas - Location
22 May 2019Complaint
22 May 2019Complaint
Identified multiple deficiencies across resident rights to communication, environment, assessments, care planning, activities, nursing coverage, infection control, and food safety.
CFR 483.10(g)(6)-(9)Right to Forms of Communication w/ Privacy
Determined the facility was in compliance with state requirements. No deficiencies were cited.
31 Jan 2019Revisit
31 Jan 2019Revisit
Determined that deficiencies cited previously were addressed and the operation returned to substantial compliance.
11 Dec 2018Complaint
11 Dec 2018Complaint
Found failures to manage constipation interventions for two residents and to ensure nurse aides had proper certification before performing duties.
CFR 483.25Quality of care
CFR 483.35(d)(1)-(3)Requirement for facility hiring and use of nurse aides
17 Oct 2018Complaint
17 Oct 2018Complaint
Investigated a complaint survey conducted between 10/16/2018 and 10/17/2018 and found no deficiencies.
17 Oct 2018Revisit
17 Oct 2018Revisit
Concluded that prior deficiencies were corrected and no new noncompliance was found during a follow-up survey.
06 Sept 2018Complaint
06 Sept 2018Complaint
Investigation identified deficiencies in wound care management and in updating care plans and nursing documentation to reflect wound care requirements.
§483.21(b)(2) Comprehensive Care PlansComprehensive Care Plans
§483.25 Quality of CareQuality of Care
§483.25 Quality of CareQuality of Care
05 Jul 2018Revisit
05 Jul 2018Revisit
Confirmed all previously identified deficiencies were corrected and no new noncompliance was found.
05 Jul 2018Revisit
05 Jul 2018Revisit
Found no deficiencies. Corrections from prior deficiencies were completed.
06 Jun 2018Revisit
06 Jun 2018Revisit
Verified that previously cited deficiencies were corrected and no new noncompliance was found.
04 May 2018Life Safety
04 May 2018Life Safety
Identified multiple life-safety deficiencies across means of egress, hazardous areas, cooking facilities, electrical safety, and fire drills.
2012 NFPA 101 Section 18.5.1.1; 19.5.1.1; 9.1.1; 9.2Continued service restrictions
2012 NFPA 101 Sections 18.5.1.1; 19.5.1.1; 9.1.2; 9.2.3; NFPA 70Electrical systems and HVAC utilities
2012 NFPA 101 9.7.8 (and related sections)Fire Drills
2012 NFPA 101 18.7.8; 19.7.8Portable Space Heaters
2012 NFPA 101 Section 9.2.3; NFPA 70; NFPA 101 9.6.xElectrical equipment - Power cords and extension cords
03 May 2018Licensure
03 May 2018Licensure
Determined a TB testing deficiency. One employee lacked a completed TB skin test and there was no documentation of the test.
Ch 11 Sec 5 (b)(iv) Organization and AdministrationTuberculin testing and employee health requirements
03 May 2018Complaint
03 May 2018Complaint
Found multiple deficiencies related to resident rights, safety, and basic care processes, including privacy, pain management, medical record access, and food handling practices.
Type A§483.10(h)(3)Resident privacy and access to confidential records
c§483.25(k)Pain management
Type A§483.25(n)(1)Bed rails and safety for residents
Type A§483.30(c)(1)-(4)Physician visits—Frequency and timeliness
Type A§483.60(i)(1)(2)Food storage and handling
26 Apr 2018Revisit
26 Apr 2018Revisit
Verified that all previously cited deficiencies were corrected and no new noncompliance was found.
26 Apr 2018Revisit
26 Apr 2018Revisit
Verified compliance after a revisit. All prior deficiencies were corrected and no new noncompliance found.
14 Mar 2018Complaint
14 Mar 2018Complaint
Investigated a complaint about bed-hold notices and discharge planning; found deficiencies in bed-hold policy notification and discharge planning processes.
CFR 483.15(d)Bed-Hold Policy Notice
CFR 483.21(c)(1)(i)-(ix)Discharge Planning Process
09 Mar 2018Revisit
09 Mar 2018Revisit
Investigated a revisit survey; all prior deficiencies were corrected and no new noncompliance was found.
04 Jan 2018Complaint
04 Jan 2018Complaint
The investigation identified several deficiencies related to resident activities, care planning, skin integrity, and staffing. Observations showed inadequate engagement, supervision, and staffing levels that affected resident well-being.
483.24(c)(1)Activities of daily living; assistance with personal hygiene and oral care; scheduled activities
483.24(c)(1)Activities program; ongoing program to meet resident interests and needs
483.25(b)(1)(i)(ii)Treatment/Services to prevent/heal pressure ulcers
483.25(d)Free of accident hazards/supervision/devices
483.35(a)(1)(2)Nursing staff; appropriate staffing levels and scheduling
483.35(d)(1)-(3)Nurse staffing; use of certified nursing assistants
483.35(g)(1)-(4)Nurse staffing data; posted information
04 Oct 2017Complaint
04 Oct 2017Complaint
Investigated a complaint and found no deficiencies.
10 Jul 2017Revisit
10 Jul 2017Revisit
Restored to compliance after addressing health and life-safety deficiencies identified in May 2017 surveys, effective June 12, 2017.
28 Jun 2017Revisit
28 Jun 2017Revisit
The agency announced the facility was brought back into compliance after follow-up surveys and confirmed on June 12, 2017.
18 May 2017Life Safety
18 May 2017Life Safety
Identified life-safety deficiencies including enclosure of vertical openings and maintenance issues with the sprinkler system; the findings spanned multiple locations and required corrective action dates.
Investigators identified deficiencies related to ownership changes, resident supervision, safety/environmental conditions, and documentation practices.
—Continued From page 2 – Ownership change and compliance
—Continued From page 3 – Staffing limitations
—Continued From page 12 – Environmental safety
11 May 2017Licensure
11 May 2017Licensure
Identified no deficiencies and found the facility in compliance with state requirements after a licensing survey.
13 Dec 2016Complaint
13 Dec 2016Complaint
Investigated a complaint survey conducted 2016-12-12 through 2016-12-13. Found no deficiencies identified.
07 Jul 2016Revisit
07 Jul 2016Revisit
Verified corrections were completed for previously cited deficiencies.
10 Jun 2016Revisit
10 Jun 2016Revisit
Cited Life Safety Code deficiencies under NFPA 101 with corrections completed in June 2016.
NFPA 101 Life Safety CodeLife Safety Code deficiency
NFPA 101 Life Safety CodeLife Safety Code deficiency
NFPA 101 Life Safety CodeLife Safety Code deficiency
21 Apr 2016Licensure
21 Apr 2016Licensure
Investigators found multiple deficiencies across housekeeping, care planning, wound prevention, staff sufficiency, and QA processes, with several items carried forward across pages indicating ongoing issues.
483.20(d)(3), 483.10(k)(2)Right to Participate in Care Planning
483.25(c)Treat/Prevent/Heal Pressure Sores
483.30(a)Sufficient 24-Hour Nursing Staff Per Care Plans
483.75(i)(1)Quality Assurance/Improvement
483.75(i)(1)Quality Assurance/Improvement
21 Apr 2016Licensure
21 Apr 2016Licensure
Determined no deficiencies. Found the facility in compliance with state requirements.
19 Apr 2016Life Safety
19 Apr 2016Life Safety
Identified two life-safety deficiencies: exit access not maintained and electrical wiring not in accordance with code.
NFPA 101 Life Safety Code StandardEXIT ACCESS
NFPA 70 National Electrical CodeElectrical wiring and equipment
28 Mar 2016Life Safety
28 Mar 2016Life Safety
Investigated a complaint and found no deficiencies identified.
22 Jan 2016Complaint
22 Jan 2016Complaint
Investigated a complaint; found no deficiencies identified.
22 Jan 2016Complaint
22 Jan 2016Complaint
Investigated the complaint and found no deficiencies.
24 Nov 2015Revisit
24 Nov 2015Revisit
Investigated the follow-up after prior deficiencies; uncorrected deficiencies were identified and a summary was sent to the facility.
—
17 Jun 2015Revisit
17 Jun 2015Revisit
Investigated a follow-up to a prior survey; previously reported deficiencies were corrected and no new deficiencies were identified.
17 Jun 2015Revisit
17 Jun 2015Revisit
Investigated the allegation and identified deficiencies during a follow-up review.
04 Jun 2015Revisit
04 Jun 2015Revisit
Investigated a prior complaint and verified deficiencies related to life-safety and licensing were addressed. A post-certification revisit confirmed corrections.
04 Jun 2015Revisit
04 Jun 2015Revisit
Verified that prior deficiencies were corrected and all corrective actions were completed.
26 Mar 2015Licensure
26 Mar 2015Licensure
Found water temperatures at showers and resident lavatories exceeded the maximum allowed; a deficiency was cited.
Investigated concerns showed privacy-related issues and multiple deficiencies in care planning and discharge processes requiring follow-up actions.
Type A483.10(a)(1) Privacy and Confidentiality of Resident RecordsPrivacy/Confidentiality
Type A483.20(d)(2) Comprehensive Care PlansDevelop Comprehensive Care Plans
Type A483.20(k)(1) Development and Implementation of Care PlansCare Planning for Residents
Type A483.20(k)(2) Action to be Taken on Corrective Action (cross-reference to appropriate deficiencies)Discharge Planning
Type A483.20(k)(3) Provider Action (corrective plans) and related requirementsCorrective Action Procedures
24 Mar 2015Life Safety
24 Mar 2015Life Safety
Identified a cross-connection risk due to a hose connection that lacked backflow prevention and was connected to the faucet discharge.
2006 IPC, Sections 608.6 and 608.13Backflow prevention and cross-connections
24 Mar 2015Life Safety
24 Mar 2015Life Safety
Found multiple life-safety deficiencies, including doors failing to resist smoke passage and missing documentation for monthly fire-system testing and related safeguards.
NFPA 101 Life Safety Code StandardDoors not resisting passage of smoke
NFPA 101 Life Safety Code StandardFire alarm system monthly test/activation documentation
NFPA 101 Life Safety Code StandardHazardous areas protected from corridor with self-closing doors
NFPA 101 Life Safety Code StandardAll residents affected by life-safety deficiencies
25 Sept 2014Revisit
25 Sept 2014Revisit
Identified deficiencies in federal care standards with uncorrected items noted.
483.13(c)(11)(ii)-(iii), (c)(2)-(4)
25 Sept 2014Revisit
25 Sept 2014Revisit
Cited two regulatory deficiencies; corrections completed.
483.10(f)(2)
483.13(c)(1)(i)(ii)-(iii), (c)(2)
30 Jul 2014Revisit
30 Jul 2014Revisit
Identified life-safety deficiencies requiring correction; corrections completed by 06/03/2014 and reviewed by CMS on 07/31/2014.
NFPA 101 Life Safety CodeLife Safety Code (NFPA 101)
NFPA 101 Life Safety CodeLife Safety Code (NFPA 101)
NFPA 101 Life Safety CodeLife Safety Code (NFPA 101)
NFPA 101 Life Safety CodeLife Safety Code (NFPA 101)
01 Jul 2014Complaint
01 Jul 2014Complaint
Identified deficiencies in handling resident grievances and in investigating and reporting an allegation of neglect/unknown-origin injury; gaps in staff training and documentation were noted.
—Resident grievance process
—Investigation/Reporting of neglect or unknown-origin injuries
01 Jul 2014Revisit
01 Jul 2014Revisit
Investigations into alleged deficiencies were initiated, with initial concerns identified about background checks and staff reporting.
483.20(d), 483.20(k)(1)CHARGE NURSES AND CNAs WERE INVOLVED IN INJURIES OF UNKNOWN ORIGIN
17 Apr 2014Licensure
17 Apr 2014Licensure
Identified deficiencies in dietetic services, including lack of full-time supervision and adherence to safe food-handling practices.
Ch 11 Sec 11 (a)(1)Dietetic Services
17 Apr 2014Complaint
17 Apr 2014Complaint
Investigated several noncompliance issues involving resident dignity and care planning, and medication record accuracy.
03 Apr 2014Life Safety
03 Apr 2014Life Safety
Investigated a deficiency with life-safety code compliance; found multiple issues affecting egress and emergency lighting that did not meet NFPA 101 standards.
NFPA 101 Life Safety Code Standard 19.2.8Delayed egress locking mechanisms
NFPA 101 Life Safety Code Standard 19.2.8Means of egress illumination
NFPA 101 Life Safety Code Standard 19.2.8Emergency lighting
NFPA 101 Life Safety Code StandardDocumentation availability
03 Apr 2014Life Safety
03 Apr 2014Life Safety
The agency identified deficiencies related to emergency eyewash equipment and ventilation/air intake systems, indicating noncompliance with applicable standards and separation requirements.
Type AANSI Z358.1; ASSE 1071; 2006 IMC (606.2, 606.4); 2006 IPC (Section 411); FGI Table 4.1-1; Chapter 4 of the 2006 IMCEmergency eyewash and ventilation system deficiencies
05 Nov 2013Complaint
05 Nov 2013Complaint
Investigated the complaint and found no deficiencies.
14 May 2013Revisit
14 May 2013Revisit
Identified deficiencies in nursing assessments and care documentation, which were corrected after follow-up.
06 Apr 2013Life Safety
06 Apr 2013Life Safety
Identified a deficiency related to emergency exit signage; an area of the building lacked a continuously illuminated exit sign.
NFPA 101 Life Safety Code, Emergency Lighting/Exit Sign RequirementsLife Safety Code deficiencies—means of egress
28 Mar 2013Complaint
28 Mar 2013Complaint
Found multiple deficiencies across privacy, nutrition, activities, records, and overall care management, indicating noncompliance with regulatory standards.
F164 - Personal PrivacyPersonal Privacy
F248 - ActivitiesActivities
F253 - Food ProcurementFood Procurement
F281 - Professional StandardsProfessional Standards
F514 - RecordsRecords
27 Mar 2013Life Safety
27 Mar 2013Life Safety
Identified deficiencies related to fire alarm certificate posting, sprinkler head/ceiling clearances, and electrical wiring practices. Corrective actions were noted to address the issues.
NFPA 101 Life Safety Code, 2000 editionCertificate of compliance not posted for fire alarm system
NFPA 101 Life Safety Code, 2000 editionSprinkler head escutcheon gaps
NFPA 101 Life Safety Code Standard; NFPA 70 (National Electrical Code)Electrical wiring and equipment; use of splitters
15 Nov 2012Revisit
15 Nov 2012Revisit
Investigated a complaint and noted that corrections were completed on follow-up.
13 Sept 2012Complaint
13 Sept 2012Complaint
Identified deficiencies in care plan auditing and hydration provision. The findings indicate care plans were not consistently audited and residents' hydration was not consistently ensured.
—Care plan audit requirements
—Sufficient Fluids Provided
30 May 2012Revisit
30 May 2012Revisit
Identified deficiencies with corrections completed.
25 May 2012Revisit
25 May 2012Revisit
Verified corrections to prior deficiencies; follow-up confirmed completed.
15 Mar 2012Complaint
15 Mar 2012Complaint
During the investigation, privacy and record-handling deficiencies were found, including failures to maintain confidentiality of residents' records and to protect residents' mail privacy, along with issues related to verification of nursing staff. These findings indicate violations were identified.
—Dignity and Privacy/Confidentiality of Records
—Right to Privacy – Privacy of Communications
—Nurse Aide Registry
15 Mar 2012Life Safety
15 Mar 2012Life Safety
The inspection found life-safety concerns, including smoke doors not meeting smoke-resistance requirements and deficiencies in maintaining essential safety systems.
NFPA 101 Life Safety Code, 2000 editionCorridor doors not smoke resistant
NFPA 101 Life Safety Code, 2000 editionSprinkler system testing
NFPA 101 Life Safety Code Standard; NFPA 70 National Electrical CodeElectrical system maintenance
23 May 2011Revisit
23 May 2011Revisit
Found no deficiencies.
22 Apr 2011Revisit
22 Apr 2011Revisit
Identified deficiencies during a revisit; corrections were completed.
22 Apr 2011Revisit
22 Apr 2011Revisit
Investigated a complaint and found no deficiencies.
11 Apr 2011Life Safety
11 Apr 2011Life Safety
Investigated life-safety deficiencies involving dumbwaiter doors and emergency lighting; reviewed photographs and noted steps taken to address the issues.
Wyoming Life Safety CodeDumbwaiter hoistway door emergency illumination
Wyoming Life Safety CodesLife Safety Standards observed and maintained; plan submission
11 Apr 2011Revisit
11 Apr 2011Revisit
Verified corrections from a prior deficiency list were completed; follow-up confirmed completion.
10 Feb 2011Complaint
10 Feb 2011Complaint
An investigation found multiple deficiencies related to resident dignity, communication about changes in condition, and environmental/service standards.
Type A483.15(a)Dignity and respect of individuality
10 Feb 2011Licensure
10 Feb 2011Licensure
Identified a deficiency in tuberculosis testing for staff; one employee worked with residents before TB test results were available.
—Tuberculosis testing not completed prior to resident contact
08 Feb 2011Life Safety
08 Feb 2011Life Safety
Investigated safety issues with storage and electrical systems, lighting, and locking requirements; multiple life-safety deficiencies were identified.
NFPA 101 LIFE SAFETY CODE STANDARDBasement storeroom safety deficiencies
NFPA 101 LIFE SAFETY CODE STANDARDInadequate lighting and emergency lighting
NFPA 101 LIFE SAFETY CODE STANDARDDamaged electrical equipment
NFPA 101 LIFE SAFETY CODE STANDARDMechanical locking requirement not understood
19 Feb 2010Revisit
19 Feb 2010Revisit
Identified deficiencies cited during a follow-up visit.
483.15(a)
26 Jan 2010Revisit
26 Jan 2010Revisit
Concluded that prior deficiencies were corrected and no outstanding issues remained.
17 Dec 2009Licensure
17 Dec 2009Licensure
Identified deficiencies in tuberculosis testing documentation for employees; records lacked TB tests for several staff hired since August 2009.
Chapter 11, Section 5 Organization and Administration (b)(iv)(A)Tuberculin testing for employees
17 Dec 2009Complaint
17 Dec 2009Complaint
Found deficiencies in resident care, including lack of dignified and timely meal assistance and gaps in care practices and documentation.
—Dignified, timely meal assistance
16 Dec 2009Life Safety
16 Dec 2009Life Safety
Identified life-safety deficiencies including under-rated corridor doors, unsealed penetrations in a smoke barrier, unprotected wet-location outlets, and portable heaters present in restricted areas.
NFPA 101 LIFE SAFETY CODE STANDARDCorridor doors not meeting 20-minute fire rating
NFPA 101 LIFE SAFETY CODE STANDARDUnsealed penetrations in smoke barrier wall
NFPA 101 LIFE SAFETY CODE STANDARDWet-location receptacles not protected by GFCI
NFPA 101 LIFE SAFETY CODE STANDARDPortable space heating devices prohibited
20 Aug 2009Revisit
20 Aug 2009Revisit
Investigated a complaint and found deficiencies related to resident rights protections and nursing services; corrections were completed before the revisit.
483.25(c)Resident rights - freedom from abuse, neglect, and exploitation
483.75(o)(1)Nursing services - care planning/assessment requirements
10 Jun 2009Complaint
10 Jun 2009Complaint
Found a deficiency in pressure sore management, with inadequate care planning and follow-through on wound care for residents.
483.25(c)PRESSURE SORES
20 Feb 2009Revisit
20 Feb 2009Revisit
Investigated deficiencies were corrected.
483.20(k)(3)(i)
483.25
483.75(o)(1)
483.25(l)
483.65(b)(3)
23 Jan 2009Revisit
23 Jan 2009Revisit
Identified deficiencies in care planning, medication management, and quality assurance processes.
483.20(k)(3)(i)Comprehensive Care Plans
483.25Unnecessary Drugs
483.75Quality Assurance and Performance Improvement
15 Jan 2009Revisit
15 Jan 2009Revisit
Verified corrections completed for cited life-safety deficiencies.
NFPA 101 Life Safety Code (LSC)K0029
NFPA 101 Life Safety Code (LSC)K0062
NFPA 101 Life Safety Code (LSC)K0076
NFPA 101 Life Safety Code (LSC)K0141
18 Nov 2008Life Safety
18 Nov 2008Life Safety
Investigated a safety concern and found deficiencies in life-safety and storage practices, including sprinkler clearance, oxygen storage, and missing smoking signage in some resident areas.
NFPA 101 LIFE SAFETY CODE STANDARDSprinkler head clearance
NFPA 101 LIFE SAFETY CODE STANDARDOxygen storage proximity/clearance
NFPA 101 LIFE SAFETY CODE STANDARDSmoking signage in resident rooms
NFPA 101 LIFE SAFETY CODE STANDARDOxygen storage security
18 Nov 2008Complaint
18 Nov 2008Complaint
Investigated findings showed deficiencies in background checks and in providing care that respects residents’ dignity and privacy.
—MISTREATMENT, NEGLECT, ABUSE, AND MISAPPROPRIATION OF RESIDENT PROPERTY
—RESIDENT CARE AND DIGNITY (RIGHTS AND PROPER CARE)
29 Aug 2007Complaint
29 Aug 2007Complaint
Investigated a complaint and found no deficiencies.
08 Feb 2007Revisit
08 Feb 2007Revisit
Found no deficiencies.
25 Jan 2007Revisit
25 Jan 2007Revisit
Identified deficiencies in several federal regulatory standards during a follow-up review.
483.10(i)(1)
483.25(h)(2)
483.35(i)(2)
483.65(b)(2)
483.70(h)(3)
483.25(c)
483.25(a)(2)
483.25(h)(1)
27 Dec 2006Revisit
27 Dec 2006Revisit
Identified life-safety deficiencies and confirmed corrective actions were completed.
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
16 Nov 2006Complaint
16 Nov 2006Complaint
Investigated a deficiency in the facility's physical environment; delayed egress locks on the front door were not maintained in working order, compromising safety.
42 CFR 483.70PHYSICAL ENVIRONMENT
09 Nov 2006Licensure
09 Nov 2006Licensure
Investigated tuberculin testing for employees and found an employee hired without the required initial test before resident contact and without annual testing completed. The finding pertained to failure to meet tuberculosis testing requirements.
Rules and Regulations for Program Administration of Nursing Care Facilities, Chapter 11, Section 5(b)(iv)(A)Tuberculin testing for employees
09 Nov 2006Complaint
09 Nov 2006Complaint
Regulators identified multiple deficiencies in resident rights, staff screening, social services, and resident assessments and care planning.
483.13(a)PHYSICAL RESTRAINTS
Type A483.13(b), 483.13(b)(1)(i)ABUSE
483.13(g)(1)(ii)(iii)STAFF SELECTION/EMPLOYMENT
Type A483.15(g)(1)SOCIAL SERVICES
483.20(b)(2)(ii)COMPREHENSIVE ASSESSMENTS
483.20(b)(2)(ii) or (k)(3)(i)RESIDENT ASSESSMENT
483.25(a)(3)ACTIVITIES OF DAILY LIVING
483.25(c)PRESSURE SORES
483.25(h)(2)HOUSEKEEPING/MAINTENANCE
30 Oct 2006Life Safety
30 Oct 2006Life Safety
The facility had life-safety and electrical-system deficiencies, including door hardware issues and incomplete testing/maintenance of safety systems, found during the investigation.
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
29 Dec 2005Revisit
29 Dec 2005Revisit
Identified multiple regulatory deficiencies and noted that corrective actions were completed.
483.15(h)(2)
483.20(k)(3)(i)
483.25(n)(2)
483.35(a)(3)
483.60(a)
483.75(b)
20 Oct 2005Licensure
20 Oct 2005Licensure
Found multiple deficiencies, including privacy and confidentiality lapses, improper staff treatment of residents, and incomplete resident assessments and care plans.
483.10(c)Privacy and Confidentiality
483.15(a)Dignity
483.13(c)Staff Treatment of Residents
483.20(d)Comprehensive Assessments
483.20(g)Comprehensive Care Plans
19 Oct 2005Revisit
19 Oct 2005Revisit
Identified four Life Safety Code deficiencies during the follow-up; all corrections completed by the specified dates.
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
22 Sept 2005Licensure
22 Sept 2005Licensure
Identified deficiencies in resident care planning and daily care activities during the inspection.
25 Aug 2005Life Safety
25 Aug 2005Life Safety
Investigated the facility for life-safety compliance and found deficiencies in sprinkler coverage and exit-door protections. Found that automatic sprinklers were not fully installed/maintained and several doors lacked self-closing devices or proper latching.
NFPA 101 Life Safety Code Standard; NFPA 13NFPA 101 Life Safety Code Standard
NFPA 101 Life Safety Code StandardNFPA 101 Life Safety Code Standard
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