Goshen Healthcare Community

    2009 Laramie St, Torrington, WY 82240
    • Independent Living
    • Assisted Living
    • Memory Care
    • Skilled Nursing

    Attentive long-tenured staff compassionate community

    I'm a resident here and very pleased with the caring, long-tenured staff-nurses, CNAs and physical therapists are excellent and attentive. Rooms are clean and well-kept, memory care and activities are supportive (the salon and social calendar are nice), meals are good, and my family feels confident in this safe, compassionate community.

    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

    3.60·(20)

    Overall rating

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

      3.1
    • Staff

      3.5
    • Meals

      4.2
    • Amenities

      3.0
    • Value

      3.0

    Pros

    • Skilled physical therapy program
    • Experienced and capable nursing staff
    • Compassionate, hardworking caregivers
    • Low staff turnover and long-tenured employees
    • Clean, odor-free environment
    • Nutritious, well-presented meals
    • Active, well-run activities program
    • Well-maintained resident rooms and salon services
    • Strong rehabilitation and post-acute support
    • Personalized family communication
    • Positive community reputation and perceived value
    • Friendly front-line staff

    Cons

    • Inconsistent staff responsiveness and professionalism
    • Insufficient staffing levels during busy periods
    • Gaps in emergency escalation and hospital-transfer procedures
    • Weak clinical documentation and referral coordination
    • Gaps in specialized wound care and specialist access
    • Rigid or poorly communicated discharge and transition processes
    • Limited private space and cramped shared-room configurations
    • Variable attention to routine room maintenance and details
    • Variable dining-service consistency
    • Inconsistent rehabilitation goal-setting and progression planning

    Summary of reviews

    Goshen Healthcare Community presents a mixture of clear strengths and areas of operational concern. Many reviewers praise clinical services such as physical therapy and nursing, describing skilled therapists, capable nursing staff, and strong rehabilitation support that benefit post-acute and restorative residents. The facility is frequently described as clean and odor-free, with well-kept resident rooms, an on-site salon, and a positive local reputation. Family communication is often characterized as personal and gracious, and the activities program is active and encouraged by staff, contributing to perceived value.

    Clinical quality appears uneven. While therapy services and many front-line caregivers are identified as effective and compassionate, reviewers also describe plateaus in rehab progress and a lack of ongoing goal-setting for some residents. There are recurring concerns about clinical coordination: documentation gaps, limited referrals to specialists, and specific deficits in specialized wound management. These issues point to variability in how resident care plans are reviewed and escalated when problems emerge.

    Staffing and conduct are mixed themes. Long-tenured, attentive employees are repeatedly noted as a strength, but there are parallel descriptions of inconsistent responsiveness, staff using personal devices while on duty, and long waits for assistance. Reviewers indicate that staffing levels can be insufficient during busy periods, which can affect timeliness of care and routine assistance. Professionalism and communication tone are generally positive in many accounts but are described as inconsistent across shifts.

    Dining and activities receive largely favorable mention. Meals are often described as good and well-presented rather than exceptional, and the activities director and programming are viewed as engaging and informative. The social and communal aspects of the facility—group meals, activities, and a pleasant interior—are strengths for residents seeking an active environment.

    Facility amenities and rooms are generally well maintained, contributing to an impression of safety and overall cleanliness. At the same time, physical-layout limitations are noted: some rooms, particularly add-on or shared configurations, feel cramped and lack amenities such as in-room entertainment. Small environmental details—clocks not updated, occasional maintenance oversights—have been called out and may indicate inconsistent attention to routine room upkeep.

    Management and transitions are areas to probe for prospective residents. Some families describe difficult interactions around discharge or care-transition decisions and report adversarial communication in specific instances. More seriously, a few accounts describe delays or reluctance in initiating emergency transfers when acute issues arose; these descriptions suggest a need to clarify the facility's emergency escalation and hospital-transfer protocols before placement. Documentation and referral processes also appear inconsistent, which can complicate specialist access and follow-up care.

    Overall, Goshen Healthcare Community offers substantive clinical and social strengths—skilled therapy, compassionate long-term staff, cleanliness, and active programming—that many families find valuable. Prospective residents and families should verify staffing levels for the expected unit and shift, ask for details about emergency-transfer policies and specialist-referral pathways, review how individualized therapy goals and wound-care plans are developed and updated, and inspect room layouts for privacy and space. These targeted questions will help determine whether the facility's strong areas align with a prospective resident's specific clinical and personal needs.

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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 Goshen Healthcare Community

    Goshen Healthcare Community is located at 2009 Laramie St, Torrington, WY, 82240.

    About Goshen Healthcare Community

    Goshen Healthcare Community sits in Torrington, WY, and it's a skilled nursing and nursing facility with 103 beds, a state license called #15185, and a focus on comfort, safety, health, and supporting independence for every resident, so folks can come for tours and see what goes on there, meet the staff, and talk to the residents themselves, which helps everyone get a feel for the place. The facility offers a wide range of care, including assisted living, memory care for those with Alzheimer's or dementia in a secure unit, independent living, home care, respite care, and continuing care for changing needs, all while nurses, clinicians, and caregivers work round the clock for both short-term and long-term needs, like medication management, help with daily living, or therapy after hospital stays. People can choose private rooms, enjoy restaurant-style meals with allergy-friendly and diabetic-safe options from a professional chef, and join in on community activities like music nights, outings to Prairie Wind Casino, and trips during Cheyenne Frontier Days, with events like movie nights, bingo, arts and crafts, and activity rooms always on the calendar.

    You'll find services for all levels of need, including everything from basic housekeeping and laundry to deep tissue therapy, stroke or cardiac recovery, and geriatric rehab, and staff pay close attention to creating personal care plans with families and doctors, so each resident gets what they need, whether it's intensive rehab, ongoing monitoring, or companionship and fun. The site is wheelchair accessible, has family support services, accepts both Medicaid and Medicare, and offers secure housing along with Alzheimer's care. There are air systems that filter out over 99.9% of particles, so the air stays clean for everyone, and there's always a 24-hour call system in case someone needs help.

    Plenty of spaces let people mix or find quiet, like community rooms, gardens, walking paths, a library, game and movie rooms, an arts room, a fitness area, and even a spa, and there's a lot of focus on keeping the setting as homelike as possible, with caring staff giving support but also treating residents with real kindness and respect. The nursing team's always there for things like pain management, wound or ostomy care, post-surgery recovery, IV therapy, palliative care for comfort near the end of life, and specialized dementia support, covering both medical and daily life needs. Transportation, move-in help, special diets, and everything from splint making to respiratory therapy are provided right onsite by experienced helpers, and there's a real family-oriented atmosphere, so loved ones can stay involved, come for meals, or join activities whenever they like. The community works hard to be a steady, honest place for seniors who need different kinds of care over time, and it aims to give every resident a sense of dignity, purpose, and comfort in a safe and caring setting, right on 2009 Laramie Street.

    People often ask...

    Goshen Healthcare Community offers independent living, assisted living, memory care, continuing care retirement community, and skilled nursing.

    There are 2 photos of Goshen Healthcare Community on Mirador.

    Yes, Goshen Healthcare Community allows residents to age in place and adjust their level of care as needed.

    The full address for this community is 2009 Laramie St, Torrington, WY 82240.

    No, Goshen Healthcare Community 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-217
    Facility typeNursing Home

    Inspection Reports

    168

    Reports

    4

    Type A Citations

    0

    Type B Citations

    60

    Complaints

    20

    Years

    24 Jul 2025Licensure
    Identified deficiencies in discharge planning, bed-hold notification, resident safety, medication management, infection control, and antibiotic stewardship. The findings indicate multiple areas where documentation and procedures did not meet regulatory requirements.
    • CFR §483.15(c)(2); §483.15(c)(3); §483.15(c)(4); §483.15(c)(5); §483.15(c)(6); §483.15(d); §483.21(c)(2)Discharge Process
    • CFR §483.25(d)Accidents
    • CFR §483.45(c)(1)-(5)Drug Regimen Review
    • CFR §483.80(a); §483.80(a)(2); §483.80(a)(4); §483.80(e); §483.80(f)Infection Prevention & Control
    • CFR §483.80(a)(3)Antibiotic Stewardship Program
    22 Jul 2025Life Safety
    Found an eyewash station lacked adequate flow, preventing hands-free use. The observation occurred in the kitchen area.
    • 2006 International Plumbing Code Section 411.1; ANSI-Z358.1 5.1.6International Plumbing Code - eyewash station requirements
    22 Jul 2025Life Safety
    Identified multiple life-safety deficiencies across building 1 and the Alzheimer’s building, including doors not self-closing, hazardous-area protections incomplete, improper exit discharge, and inadequate testing and maintenance of emergency lighting, fire alarm, and sprinkler systems.
    • NFPA 101, 19.2.2.2.7Doors with Self-Closing Devices
    • NFPA 101, 18.2.7, 19.2.7Discharge from Exits
    • NFPA 101, 18.2.9.1, 19.2.9.1Emergency Lighting
    • NFPA 101, 19.3.2.1, 8.7.1Hazardous Areas - Enclosure
    • NFPA 101, 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8; NFPA 70, NFPA 72Fire Alarm System - Installation
    • NFPA 101, 9.6.1.3, 9.6.1.5; NFPA 70, NFPA 72Fire Alarm System - Testing and Maintenance
    • NFPA 101, 19.3.5, 9.7, 9.7.1.1(1); NFPA 13Sprinkler System - Installation
    • NFPA 101, 9.7.5, 9.7.7, 9.7.8; NFPA 25Sprinkler System - Maintenance and Testing
    • NFPA 101, 18.3.5.12, 19.3.5.12; NFPA 10Portable Fire Extinguishers
    • NFPA 101, 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2; NFPA 54Utilities - Gas and Electric
    • NFPA 101, 18.7.5.1, 18.3.5.11, 19.7.5.1, 19.3.5.11, 10.3.1; NFPA 701Draperies, Curtains, and Loosely Hanging Fabrics
    • NFPA 101, 19.7.6, 8.3.3.1 (LSC); NFPA 80Maintenance, Inspection & Testing - Doors
    • NFPA 99, 6.3.3.2, 6.3.4.1.3Electrical Systems - Maintenance and Testing
    • NFPA 99, 6.4.4.1.2; NFPA 110Electrical Systems - Essential Electric System
    • NFPA 99, 10.2.3.6, 10.2.4; NFPA 70, 400-8Electrical Equipment - Power Cords and Extension Cords
    • NFPA 99, 11.3.1–11.3.4, 11.6.5Gas Equipment - Cylinder and Container Storage
    18 Jul 2025Revisit
    Confirmed all prior deficiencies were corrected and found no new noncompliance.
    17 Jun 2025Complaint
    Investigated found that the abuse reporting policy was not followed and a timely report of suspected abuse was not made in several cases.
    • CFR 483.12(b)(5)(i)(A)(B)(c)(1)(4)Reporting of alleged violations
    09 Apr 2025Revisit
    Verified that all previous deficiencies were corrected and no new noncompliance was found.
    04 Feb 2025Complaint
    Investigated a complaint alleging unprescribed medications were given to residents; found deficiencies in chemical restraint practices, investigation documentation, and adherence to professional care standards.
    • CFR 483.10(e)(1); CFR 483.12(a)(2)Right to be Free from Chemical Restraints
    • CFR 483.12(c)(2)-(4)Investigate/Prevent/Correct Alleged Violation
    • CFR 483.21(b)(3)(i)Services Provided Meet Professional Standards
    10 Jul 2024Complaint
    Investigated a complaint and found no deficiencies identified.
    16 May 2024Complaint
    Concluded that no deficiencies were identified related to the complaint investigation.
    18 Apr 2024Complaint
    Investigated and identified deficiencies related to advance directives, resident care, staff verification, psychotropic medication monitoring, food safety, and infection control.
    • CFR 483.10(c)(6); 483.10(c)(8); 483.10(g)(12)Right to accept or refuse medical treatment and advance directives
    • CFR 483.24(a)(2)ADL care provided for dependent residents
    • CFR 483.35(d)(4)-(6)Nurse aide registry verification and retraining
    • CFR 483.45(e)(1)-(5)Psychotropic drug use and monitoring
    • CFR 483.60(i)(1)-(2)Food safety: procurement, storage, and handling
    • CFR 483.80(a)(1)-(4); 483.80(e); 483.80(f)Infection prevention and control
    17 Apr 2024Life Safety
    Found deficiencies in life safety code compliance, including issues with exit discharge, hazardous area enclosures, and maintenance/testing of fire alarm and sprinkler systems.
    • NFPA 101, 19.2.1; 7.1.6Discharge from Exits
    • NFPA 101, 19.3.2.1.2; 8.4Hazardous Areas - Enclosure
    • NFPA 101, 19.3.4.1; 9.6.1.3; NFPA 72, Table 14.4.5Fire Alarm System - Testing and Maintenance
    • NFPA 101, 9.7.5; NFPA 25, 5.3.2Sprinkler System - Maintenance and Testing
    07 Mar 2024Revisit
    Verified compliance with all regulations; no deficiencies found.
    30 Jan 2024Revisit
    Verified compliance with all regulations; no deficiencies were found.
    23 Jan 2024Complaint
    Investigated a complaint and found deficiencies in grievance handling and care delivery, including unresolved grievances and failure to follow the care plan for meals.
    • CFR 483.10(j)Grievances
    • CFR 483.25Quality of care
    13 Dec 2023Complaint
    Identified that a resident's decline of COVID-19 vaccination was not honored, leading to an inappropriately administered vaccine and inconsistent consent documentation.
    • CFR 483.80(d)(3)(i)-(vii)COVID-19 Immunization
    09 Nov 2023Revisit
    Verified that all prior deficiencies were corrected and no new noncompliance was found; compliance with all regulations surveyed was achieved.
    20 Sept 2023Complaint
    Found violations related to resident self-determination and improper use of restraints.
    • CFR 483.10(f) Self-determinationSelf-Determination
    • CFR 483.10(e)(1), 483.12(a)(2)Right to be Free from Physical Restraints
    16 Mar 2023Revisit
    Verified that prior deficiencies were corrected and no new noncompliance was found; in compliance with all regulations surveyed.
    06 Mar 2023Revisit
    Verified compliance with life safety and emergency preparedness requirements after a revisit; all previous deficiencies were corrected.
    26 Jan 2023Licensure
    Identified multiple deficiencies in activities program supervision, fall prevention supervision, medication administration, and infection control.
    • CFR 483.24(c)(2)Qualifications of Activity Professional
    • CFR 483.25(d)(1)-(2)Free of Accident Hazards/Supervision/Devices
    • CFR 483.45(a)-(b)(3)Pharmacy Services
    • CFR 483.80(a)-(f)Infection Prevention & Control
    26 Jan 2023Revisit
    Investigated and found no deficiencies; determined to be in compliance with state requirements.
    25 Jan 2023Life Safety
    Identified multiple deficiencies in emergency preparedness and life safety, including outdated plans, missing volunteer policies, power/fuel reliability issues, egress obstructions, self-closing doors not properly latched, cooking and sprinkler system concerns, and electrical safety hazards.
    • 42 CFR 483.73(a)Develop Emergency Preparedness Plan; Review and Update Annually
    • 42 CFR 483.73(b)(6)Policies and Procedures - Volunteers and Staffing
    • 42 CFR 483.73(e)Emergency and Standby Power; Fuel Reliability
    • NFPA 101, 2012 edition; 7.1.10.1; 19.7.3.1Means of Egress - General
    • NFPA 101 7.2.1.8.2Doors with Self-Closing Devices
    • NFPA 101 19.3.2.5.5; 9.2.3; NFPA 96 12.1.2.3Cooking Facilities
    • NFPA 13 9.2Sprinkler System - Installation
    • NFPA 54; NFPA 70Utilities - Gas and Electric
    • NFPA 101 19.5.1; 9.1.2; NFPA 99 6.4.1; NFPA 110 5.1Electrical Systems - Other
    • NFPA 101 19.5.1.1; NFPA 70 210.8(B)(5)Electrical Equipment - Other
    • NFPA 101 9.1.2; NFPA 70 400-8; NFPA 70 590.3(D); NFPA 99 10.2.3.6; 10.2.4Electrical Equipment - Power Cords and Extension Cords
    • NFPA 101 19.7.5.6Combustible Decorations
    15 Dec 2022Revisit
    Found no deficiencies after a follow-up review of prior deficiencies; no new noncompliance was found.
    22 Aug 2022Complaint
    Investigated a complaint and found no deficiencies identified.
    18 Jan 2022Revisit
    Concluded that all previously cited deficiencies were corrected and no new noncompliance was found. Confirmed compliance with all regulations surveyed.
    04 Nov 2021Licensure
    Identified deficiencies in diagnoses accuracy, staffing postings, dietary qualifications, food safety, and infection prevention.
    • CFR 483.20(g)Accuracy of Assessments
    • CFR 483.35(g)(1)-(4)Posted Nurse Staffing Information
    • CFR 483.60(a)(1)-(2)Qualified Dietary Staff
    • CFR 483.60(i)(1)-(2)Food Procurement,Store/Prepare/Serve-Sanitary
    • CFR 483.80(a)(1)-(2), 483.80(a)(4), 483.80(e), 483.80(f)Infection Prevention & Control
    02 Nov 2021Life Safety
    Found multiple life safety deficiencies related to means of egress, exit signage, hazardous material storage, sprinkler system maintenance, and portable extinguishers.
    • NFPA 101: 19.2.2.2.1; 7.2.1.4.5Means of Egress - General
    • NFPA 101: 7.2.1.8.2Doors with Self-Closing Devices
    • NFPA 101: 19.2.10.1; 7.10.1.1; 7.10.1.5.1Exit Signage
    • NFPA 101: 19.3.2.6(7); NFPA 30Alcohol Based Hand Rub Dispenser (ABHR)
    • NFPA 101: 4.6.12.2; NFPA 25Sprinkler System - Maintenance and Testing
    • NFPA 101: 7.2.1; 7.2.4 (NFPA 10: 2010)Portable Fire Extinguishers
    02 Sept 2021Revisit
    Verified prior deficiencies were corrected and no new noncompliance was found.
    29 Jun 2021Complaint
    Investigated a sexual touching incident and failures in abuse reporting; identified deficiencies in ensuring protection from unwanted sexual touching and in timely reporting of alleged abuse.
    • §483.12(a)(1)Freedom from Abuse and Neglect
    • §483.12(c)(1), §483.12(c)(4)Reporting of Alleged Violations
    06 May 2021Complaint
    Investigated a complaint and a COVID-19 infection-control survey. No deficiencies were identified.
    23 Mar 2021Revisit
    Found no deficiencies.
    19 Jan 2021Complaint
    Investigated deficiencies found failures to provide compassionate care visits during a COVID-19 outbreak and to promptly notify physicians and families of changes in condition, resulting in harm.
    • CFR 483.10(f)(4)(vi)(A)-(D)Inform Visitation Rights/Equal Visitation Prvl
    • CFR 483.10(g)(14)(i)-(iv)(15)Notify of Changes (Injury/Decline/Room, etc.)
    06 Jan 2021Licensure
    Found no deficiencies related to the complaint investigations or infection control practices.
    15 Oct 2020Revisit
    Concluded that the facility was in compliance with Federal requirements after a follow-up survey addressing a prior complaint. No deficiencies were cited.
    08 Oct 2020Licensure
    Found deficiencies in infection prevention and control, including improper PPE use and insufficient social distancing on two units during a COVID-19 response.
    • §483.80 Infection ControlInfection Prevention & Control
    29 Sept 2020Licensure
    Found no deficiencies related to infection control.
    28 Aug 2020Revisit
    Verified that all previous life safety deficiencies were corrected and compliance has been restored.
    28 Aug 2020Revisit
    Verified compliance with all regulations after a revisit; all previous deficiencies were corrected.
    13 Aug 2020Complaint
    Investigated sexual abuse prevention failures and late reporting of alleged abuse. Violations were cited for abuse prevention and for reporting obligations.
    • CFR 483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
    • CFR 483.12(c)(1)-(4)Reporting of Alleged Violations
    09 Apr 2020Licensure
    Determined that no deficiencies were identified in the COVID-19 focused infection control survey.
    13 Feb 2020Complaint
    Identified multiple deficiencies across several care areas, including resident rights, assessments, discharge planning, pain management, social services, pharmacy practices, dietary management, and infection control.
    • CFR 483.10(a)(1)-(2); 483.10(b)(1)-(2)Resident Rights
    • CFR 483.20(g)Accuracy of Assessments
    • CFR 483.21(c)(2)Discharge Summary
    • CFR 483.25(k)Pain Management
    • CFR 483.40(d)Provision of Medically Related Social Services
    • CFR 483.45Pharmacy Services
    • CFR 483.45(g)-(h)Label/Store Drugs and Biologicals
    • CFR 483.60(a)-(a)(1)-(4)Qualified Dietary Staff
    • CFR 483.80(a)(1)-(2); 483.80(a)(4); 483.80(e); 483.80(f)Infection Prevention & Control
    13 Feb 2020Licensure
    Determined in compliance with state requirements after survey; found no deficiencies.
    11 Feb 2020Life Safety
    Identified deficiencies in egress door locking arrangements and in battery-powered emergency lighting during a February 2020 health and safety review.
    • NFPA 101, 18.2.2.2.4; 19.2.2.2.4; 7.2.1.6.1.1(3)Egress locking arrangements
    • NFPA 101, 7.9; 18.2.9.1; 19.2.9.1Emergency Lighting
    11 Feb 2020Life Safety
    Identified multiple life-safety and electrical deficiencies, including blocked exits, nonfunctional delayed egress, missing emergency lighting, unsecured hazardous areas, unsealed smoke barrier penetrations, and improper use of power strips.
    • 2012 NFPA 101, 19.7.3.1; 7.1.10.1; 19.2.2.2.4; 7.2.1.5.3Means of Egress - General
    • 2012 NFPA 101, 19.2.2.2.4; 7.2.1.6.1.1(3)Egress Doors
    • 2010 NFPA 110, 7.3.1Emergency Lighting
    • 2012 NFPA 101, 19.3.2; 8.7.1.1Hazardous Areas - Enclosure
    • 2012 NFPA 101, 19.3.7.3; 8.6.7.1(1)Subdivision of Building Spaces - Smoke Barrier
    • 2012 NFPA 101, 19.5.1.1; 9.1.2; 2012 NFPA 99, 10.2.4; 10.2.3.6; 2011 NFPA 70, 400-8Electrical Equipment - Power Cords and Extension Cords
    11 Feb 2020Life Safety
    Identified deficiencies in protecting potable water and in providing continuous mechanical exhaust ventilation, including removed sink aerators and lack of continuous ventilation in bathing rooms.
    • WDH Chapter 3 Section 5(b)(iv)(E)Potable water protection
    • WDH Chapter 3 Section 5(b)(iv)(B)Continuous mechanical exhaust ventilation
    11 Feb 2020Life Safety
    Observed lack of continuous mechanical exhaust ventilation throughout the facility and presence of sink aerators in multiple locations, creating safety concerns.
    • WDH Chapter 3 Section 5(b)(iv)(E)State Miscellaneous Life Safety
    04 Nov 2019Complaint
    Investigated a complaint; found no deficiencies identified.
    28 Oct 2019Revisit
    Verified compliance after a complaint follow-up; all deficiencies were corrected and no new noncompliance was found.
    05 Sept 2019Complaint
    Investigated a complaint and identified failure to notify a physician and the resident's family about a change in condition for one of three sampled residents. Observed edema changes and lack of timely communication during the episode.
    • §483.10(g)(14)Notification of Changes
    • §483.15(c)(2)Availability of information to physician
    12 Jun 2019Complaint
    Found no deficiencies. The complaint investigation identified no violations.
    12 Jun 2019Revisit
    Verified no deficiencies were found on the follow-up visit.
    12 Jun 2019Revisit
    Verified prior deficiencies were corrected and no new noncompliance was found.
    16 Apr 2019Revisit
    Concluded that all prior life safety deficiencies were corrected and compliance was restored.
    12 Mar 2019Complaint
    Found that daily living activities support was not provided for a resident who required extensive assistance with walking and personal care.
    • 42 CFR 483.24Activities of daily living (ADLs)
    28 Feb 2019Complaint
    Identified multiple deficiencies across transfer/discharge notices, bed-hold information, PASARR screening, medication management, PRN psychotropic use, dietary staffing qualifications, and kitchen sanitization practices.
    • §483.15(c)(3)-(6)(8)Notice Requirements Before Transfer/Discharge
    • §483.15(d)(1)-(2)Bed-Hold Notice Upon Transfer
    • §483.20(k)(1)-(3)PASARR Screening for MD & ID
    • §483.45(c)(1)(2)(4)(5)Drug Regimen Review
    • §483.45(e)(1)-(5)Free from Unnecessary Psychotropic Meds/PRN Use
    • §483.60(a)(1)-(2)Qualified Dietary Staff
    • §483.60(i)(1)-(2)Food Safety/Sanitation
    28 Feb 2019Licensure
    Concluded that no violations were cited and state requirements were met.
    26 Feb 2019Life Safety
    Identified deficiencies in emergency lighting testing and battery maintenance during a Life Safety Code survey. Specifically, annual tests and monthly battery maintenance were not documented as required.
    • NFPA 101 Life Safety CodeEmergency lighting and battery maintenance deficiencies
    19 Sept 2018Revisit
    Found no deficiencies after a revisit on 03/19/2018; all regulations surveyed were met.
    10 May 2018Complaint
    Found no deficiencies related to the complaint investigation.
    04 May 2018Revisit
    Investigated previous deficiencies; all deficiencies were corrected and no new noncompliance found.
    06 Apr 2018Revisit
    Found no deficiencies. All previous deficiencies were corrected, and no new noncompliance was found.
    21 Mar 2018Life Safety
    Investigated several fire-safety deficiencies, including missing or incomplete testing records for emergency lighting, smoke detectors, and fire alarm components, plus issues with sprinkler system signaling.
    • NFPA 101; NFPA 72Fire alarm system - testing and sensitivity records
    • NFPAControl valve signaling
    • NFPA 101; NFPA 72Pull station / smoke compartment testing
    19 Mar 2018Revisit
    Found no deficiencies after a follow-up review and all regulations surveyed were met.
    31 Jan 2018Life Safety
    Identified life-safety deficiencies due to blocked egress paths and improper exit door/locking configurations, with multiple obstructed exits and inadequate signage observed.
    • NFPA 101, 2012; 19.2.2.2.4(2)Means of Egress - General
    • NFPA 101, 2012; 19.2.2.2.4(2)Locks and Egress Doors
    • NFPA 101, 2012; 3.1.6 (minimum exit/egress width provisions)Clear Width of Exit and Exit Access Doors
    31 Jan 2018Life Safety
    Observed a plumbing life-safety deficiency: a hand-wash sink lacked a mixing valve, which was later installed.
    • 2006 International Plumbing CodeState Miscellaneous Life Safety/Plumbing not maintained
    25 Jan 2018Complaint
    Investigated a complaint that revealed deficiencies related to resident involvement in care planning and related documentation.
    • INITIAL COMMENTS
    25 Jan 2018Licensure
    Found that the dietary manager did not meet the required qualifications and supervision for dietary services was not properly ensured.
    • Type AS3001 Chapter 11 Sec 11 (a)(i) Dietetic ServicesDietary Services - Dietary Manager Qualifications
    09 Mar 2017Revisit
    Found multiple deficiencies cited under CMS regulations with corrective actions completed by mid-February 2017.
    • 483.24(c)(1)
    • 483.10(i)(2)
    • 483.20(b)(2)(ii)
    • 483.21(b)(3)(ii)
    • 483.24(a)(2)
    • 483.25(b)(1)
    • 483.25(d)(1)(2)(n)(1)-(3)
    • 483.60(d)(1)(2)
    • 483.80(a)(1)(2)(4)(e)(f)
    09 Mar 2017Revisit
    Verified that prior deficiencies were corrected. A deficiency identified as S2924 (Ch 11 Sec 6 (a)(iv)) was corrected on 2017-02-13.
    • Ch 11 Sec 6 (a)(iv)Life Safety Code deficiency
    12 Jan 2017Licensure
    Investigated high hot-water temperatures with readings above safe limits and corrective steps were taken to lower them.
    • Ch 11 Sec 6 (a)(iv) Physical EnvironmentWater temperature controls
    12 Jan 2017Complaint
    The agency found deficiencies related to care plan compliance and facility maintenance after investigation into a complaint. Observations showed failures to follow written care plans and maintain required housekeeping standards.
    • 483.10(1)(2)Housekeeping & Maintenance Services
    11 Jan 2017Life Safety
    Investigated the complaint and found no deficiencies related to life safety code compliance.
    26 Feb 2016Revisit
    Identified multiple regulatory deficiencies across care, rights, and safety standards; several corrected in February 2016.
    • 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
    • 483.15(a)
    • 483.15(h)(2)
    • 483.20(d)(3), 483.10(k)(2)
    • 483.20(k)(3)(ii)
    • 483.30(a)
    • 483.25(d)
    • 483.60(a),(b)
    • 483.25(e)(2)
    • 483.25(i)
    26 Feb 2016Complaint
    Investigated the complaint and found no deficiencies.
    05 Feb 2016Revisit
    Found no deficiencies. No violations were cited.
    05 Feb 2016Revisit
    Verified that deficiencies previously reported were corrected and follow-up actions completed.
    17 Dec 2015Licensure
    Concluded compliance with state requirements after a survey completed in December 2015.
    17 Dec 2015Complaint
    An investigation found deficiencies across multiple areas including resident dignity, privacy, safety, and facility maintenance, with required corrective actions identified.
    15 Dec 2015Life Safety
    Found that emergency eyewash stations did not have temperature-activated mixing valves, making them noncompliant with applicable standards.
    • 2006 IPC, Sections 411IPC Life Safety – Intl Plumbing Code
    15 Dec 2015Life Safety
    Found life-safety deficiencies: hazardous areas were not adequately protected by self-closing doors, and some door locks were not single-operation as required.
    • 2000 NFPA 101, Sections 19.2.2.2.1 and 7.2.1.5.4Life Safety Code Standard
    • NFPA Life Safety Code StandardLife Safety Code Standard
    24 Sept 2015Revisit
    Found no deficiencies. Prior corrections appear complete.
    18 Aug 2015Revisit
    Completed corrections for previously reported deficiencies.
    12 Aug 2015Revisit
    Identified deficiencies in pain management and diet texture administration, with prescribed medications and therapeutic diets not consistently followed.
    • Provide Care/Services for Highest Well Being
    • Therapeutic Diet Prescribed by Physician
    07 Aug 2015Revisit
    Investigated a follow-up to a prior deficiency and found that corrections were completed.
    04 Jun 2015Licensure
    Determined that the facility was in compliance with state requirements. No deficiencies were cited.
    04 Jun 2015Complaint
    An investigation found deficiencies in resident care planning, monitoring and safety practices, with multiple corrective actions noted.
    03 Jun 2015Life Safety
    Investigated life-safety deficiencies identified improper storage near oxygen cylinders and electrical panels, a missing door closer, and lack of fire drill documentation.
    • NFPA 101 LIFE SAFETY CODE STANDARDDoor closer missing on dietician storage room
    • NFPA 101 LIFE SAFETY CODE STANDARDFire drill documentation not maintained
    • NFPA 101 LIFE SAFETY CODE STANDARDStorage near oxygen cylinders
    • NFPA 101 LIFE SAFETY CODE STANDARDElectrical panel clearance/storage near panel
    28 Apr 2015Revisit
    Verified corrections for previously cited deficiencies; no new deficiencies were identified.
    02 Apr 2015Revisit
    Investigated and found substantial compliance after follow-up; corrections completed for identified deficiencies.
    19 Feb 2015Revisit
    Identified deficiencies and confirmed corrections completed.
    • 483.13(c)(1)(ii)(iii), (c)(2)-(4)Residents' rights
    • 483.15(a)Admission, transfer, and discharges; general standards
    • 483.15(h)(2)Rights/resident choice and independence
    • 483.20(d)Comprehensive assessment data (MDS) and care planning
    • 483.20(d)(3)MDS/cac or related requirements
    • 483.25(i)Dietary services
    • 483.60(b), (d), (e)Water, sanitation, and waste management; general physical environment
    • 483.75Facility responsibilities and rights; quality of life
    • 483.25(a)(3)Dietary and menu planning
    • 483.25(m)(1)Dietary; special needs and preferences
    04 Dec 2014Complaint
    Cited deficiencies show inadequate staff credential verification and gaps in resident care oversight, including failure to check the CNA registry before hiring.
    • Initial Comments
    04 Dec 2014Licensure
    Identified deficiencies in TB risk assessment for new employees and missing TB-related documentation; lacked a system to evaluate TB risk for new hires.
    • TB risk assessment for new employees
    03 Dec 2014Life Safety
    Found deficiencies in plumbing/backflow prevention and cross-connection controls, along with electrical safety issues related to equipment rooms and beverage dispensers.
    • IPC (International Plumbing Code) 608.6; 608.13.9; 608.16Backflow prevention and cross-connection control
    • NEC (National Electrical Code)Electrical safety – equipment rooms and beverage dispensers
    03 Dec 2014Life Safety
    Identified several life-safety deficiencies related to egress and door hardware, requiring corrective actions to improve compliance.
    • NFPA 101 Life Safety Code StandardLinen/Storage door closures
    • NFPA 101 Life Safety Code StandardDoor release/egress hardware
    • NFPA Life Safety Code StandardDoor closers/egress clearance
    25 Sept 2014Revisit
    Investigated a complaint and found deficiencies were corrected; follow-up confirmed corrections.
    24 Sept 2014Revisit
    Identified deficiencies in CMS regulatory requirements; corrections were completed and verified.
    • 483.13(c)Resident rights: Freedom from abuse, neglect, and exploitation
    • 483.20(d)CMS 483.20(d) – Rights: Protection from abuse, neglect, and exploitation
    • 483.20(k)(1)CMS 483.20(k)(1) – Notice of admission, transfer, discharge rights
    • 483.25(e)(2)CMS 483.25(e)(2) – Resident funds/safeguarding
    • 483.25(h)CMS 483.25(h) – Rights/Quality of Life provisions
    • 483.35(i)CMS 483.35(i) – Resident rights and activities of daily living
    • 483.25(e)(2)CMS 483.25(e)(2) – Resident funds/safeguarding (additional item)
    • 483.75(o)(1)CMS 483.75(o)(1) – Administrative/financial oversight
    24 Sept 2014Revisit
    Investigated a complaint and identified deficiencies in several regulatory areas. A follow-up visit was conducted.
    • 483.13(c)
    • 483.20(d), 483.20(k)(11)
    • 483.20(k)(3)(i)
    • 483.25(e)(2)
    • 483.35(i)
    24 Sept 2014Revisit
    Investigated uncorrected deficiencies and confirmed corrections completed for the cited items.
    19 Jun 2014Complaint
    Identified multiple deficiencies involving resident safety, care planning, infection control, nutrition, and staff practices.
    • Policies on mistreatment, neglect, and abuse
    • Resident handling/safety
    • Care planning / plan of correction
    • Professional standards
    • Resident safety / fall prevention
    • Food service sanitation
    • Infection control / isolation
    19 Jun 2014Licensure
    Found insufficient nursing staff to meet residents' needs.
    • Ch 11 Sec 9 (c)(iii) Nursing ServicesNursing Services
    19 Jun 2014Life Safety
    Observed multiple life-safety deficiencies, including improper smoke barriers, smoke partitions, sprinkler system supervision, and exit/egress provisions.
    • NFPA 101 Life Safety Code StandardHazardous area separation and smoke-resistant doors
    • NFPA 101 Life Safety Code StandardSmoke partitions between hazardous areas and corridors
    • NFPA 101 Life Safety Code StandardExit access and egress provisions
    • NFPA 101 Life Safety Code StandardSprinkler system installation and supervision
    • NFPA 101 Life Safety Code StandardExit devices and corridor egress
    19 Jun 2014Licensure
    Identified deficiencies in restorative nursing care and the implementation of a restorative program; residents did not receive planned restorative services.
    • Rules and Regulations for Licensure of Nursing Care Facilities, Chapter 11 and Chapter 19Restorative Nursing/Restorative Care Program
    11 Mar 2014Revisit
    Identified deficiencies related to resident rights and quality of life, with corrections completed.
    • 483.25(h)Resident Rights - Protection from abuse, neglect, exploitation
    • 483.65Quality of Life - Activities and Services
    11 Mar 2014Revisit
    Verified corrections completed after prior deficiencies were found; follow-up confirmed compliance.
    29 Jan 2014Revisit
    Investigated findings identified deficiencies in governance and administration, including lack of a full-time licensed administrator.
    • Ch 11 Sec 5 (a)(iv)Organization and Administration
    29 Jan 2014Revisit
    Found deficiencies related to infection control and resident safety, including failure to follow up on care plans and improper infection-prevention practices.
    17 Dec 2013Revisit
    Identified multiple life-safety code deficiencies with corrections completed on 12/08/2013.
    • NFPA 101 Life Safety CodeLife Safety Code deficiency (K0038)
    • NFPA 101 Life Safety CodeLife Safety Code deficiency (K0069)
    • NFPA 101 Life Safety CodeLife Safety Code deficiency (K0075)
    25 Oct 2013Licensure
    An investigation identified deficiencies related to resident safety and care documentation, including issues with supervision and incident reporting.
    • Summary of deficiencies and plan of correction (observed falls, supervision, and documentation issues)
    25 Oct 2013Complaint
    Identified deficiencies in resident care and safety practices, including gaps in care planning, supervision, and daily monitoring.
    22 Oct 2013Life Safety
    Identified life-safety deficiencies including obstructed corridors and inadequate cleaning/maintenance of exhaust and waste systems.
    • NFPA 101 LIFE SAFETY CODE STANDARDCorridors unobstructed; doors projecting into corridors
    • NFPA 101 LIFE SAFETY CODE STANDARD8-3 Cleaning; hood/ducts and related components maintenance
    • NFPA 101 LIFE SAFETY CODE STANDARDCleaning and waste/linen handling standards
    05 Apr 2013Revisit
    Corrected deficiencies identified in prior findings.
    • 483.15(c)(6)483.15(c)(6)
    • 483.20(g) - (i)483.20(g) - (i)
    • 483.20(d), 483.20(k)(1)483.20(d), 483.20(k)(1)
    • 483.20(d)(3), 483.20(k)(2)483.20(d)(3), 483.20(k)(2)
    • 483.25(l)(1)483.25(l)(1)
    • 483.25(i)483.25(i)
    • 483.60(c)483.60(c)
    • 483.60(b), (d), (e)483.60(b), (d), (e)
    • 483.75(l)(1)483.75(l)(1)
    • 483.25(i) or related provision483.25(i) or related provision
    25 Jan 2013Licensure
    Determined that the facility was in compliance with state requirements after a survey conducted January 22–25, 2013.
    25 Jan 2013Licensure
    Found deficiencies related to resident care planning and overall care oversight, with several pages documenting ongoing concerns and required corrective actions.
    23 Jan 2013Life Safety
    Detected life-safety deficiencies: corridors were not maintained unobstructed and sprinkler-head installations did not meet code.
    • NFPA 101 Life Safety Code StandardContinued From page 1 - Corridor obstruction and improper sprinkler heads
    23 Jan 2013Revisit
    Verified corrections were completed after a follow-up; prior deficiencies were addressed.
    28 Sept 2012Revisit
    Follow-up determined corrections for previously reported deficiencies were completed; a revisit occurred on 2012-09-28.
    11 Sept 2012Revisit
    Identified life-safety code deficiencies during the revisit. A follow-up was conducted to verify corrections.
    • NFPA 101 Life Safety Code, K0064Life Safety Code deficiency - K0064
    • NFPA 101 Life Safety Code, K0070Life Safety Code deficiency - K0070
    • NFPA 101 Life Safety Code, K0147Life Safety Code deficiency - K0147
    26 Jul 2012Licensure
    Investigators found deficiencies related to posting and availability of survey recertifications and related oversight; a 2011 recertification survey was posted, while another completed survey was not accessible to residents or the public.
    • Recertification survey posted/not accessible
    26 Jul 2012Licensure
    Found no deficiencies during a recertification survey conducted from 7/23/12 through 7/26/12.
    24 Jul 2012Life Safety
    Investigated life-safety and electrical safety issues; found a portable fire extinguisher not properly maintained and an overdue hydrostatic test, plus an electrical plug/cord safety concern in room 201.
    • NFPA 101 Life Safety CodeLIFE SAFETY CODE STANDARD
    • NFPA 70 / NFPA 101ELECTRICAL SAFETY
    14 Feb 2012Revisit
    Found no deficiencies. The revisit confirmed prior corrections.
    14 Feb 2012Revisit
    Investigated a complaint; follow-up confirmed corrections were completed.
    09 Feb 2012Revisit
    Identified deficiencies related to life-safety standards; corrections completed.
    22 Dec 2011Licensure
    Found violations of state rules due to unsafe water temperatures in one unit, with sinks recording 118-120 degrees Fahrenheit. Maintenance could not maintain temperatures within a safe range.
    • Wyoming Rules and Regulations for the Program Administration of Nursing Care Facilities, Chapter 11, Section 6(iv)Physical Environment – Water Temperature
    22 Dec 2011Licensure
    Investigated a facility issue and found deficiencies related to resident assessments and care planning, including missing MDS assessments and incomplete care documentation.
    • 483.20(b)(1)COMPREHENSIVE ASSESSMENTS
    20 Dec 2011Life Safety
    Identified life-safety deficiencies during the inspection, including issues with smoke barrier doors, penetrations, sprinkler coverage, and alarm/egress practices.
    • NFPA 101 Life Safety Code StandardSmoke barrier doors and alarm systems
    • NFPA 101 Life Safety Code StandardGaps around penetrations in storage areas
    • NFPA 101 Life Safety Code StandardSprinkler coverage / life-safety equipment
    • NFPA 101 Life Safety Code StandardLocking/egress devices
    • NFPA 101 Life Safety Code StandardFire alarm system / door safety
    08 Dec 2011Revisit
    Identified deficiencies during follow-up and noted uncorrected deficiencies were summarized and sent.
    • 483.25(d)
    06 Oct 2011Complaint
    Observed deficiencies in catheter care and infection prevention for residents with suprapubic catheters, including missed prescribed care and inadequate treatments.
    • Type AInfection prevention and catheter care
    24 Jun 2011Revisit
    Verified that cited deficiencies were corrected during the follow-up visit.
    • 483.15(f)(1)
    • 483.20(b)(1)
    • 483.20(c) - (i)
    • 483.20(k)(3)(i)
    • 483.20(k)(3)(ii)
    • 483.25
    • 483.25(d)
    • 483.25(l)
    • 483.60(a), (b)
    17 Jun 2011Revisit
    Identified life-safety code deficiencies with required corrections; all cited items were addressed through follow-up actions.
    • 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
    21 May 2011Licensure
    Concluded no deficiencies were identified during the licensure survey.
    14 Apr 2011Licensure
    An inquiry identified multiple deficiencies in activity planning, resident care plans, and medication management; observers found gaps in implementation and documentation of residents' needs and treatments.
    • Activity program and resident preferences not fully addressed
    • Care plan/activities not aligned with resident needs
    • Comprehensive assessments not conducted or documented
    • Care plan updates not reflected across required areas
    • Medication regimen not properly managed
    • Pharmacy services oversight incomplete
    11 Apr 2011Life Safety
    Found life-safety deficiencies related to sprinkler obstructions and maintenance, with related documentation concerns noted during the survey.
    • 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
    22 Oct 2010Complaint
    Investigated a complaint in Torrington, Wyoming on 10/22/2010; found no deficiencies identified.
    19 Aug 2010Revisit
    Investigated and concluded corrective actions were completed for identified deficiencies.
    19 Aug 2010Revisit
    Investigated a complaint and found that previously identified deficiencies were corrected and follow-up completed.
    14 Jul 2010Revisit
    Found deficiencies during a follow-up evaluation; corrections were completed by the follow-up date.
    03 Jun 2010Life Safety
    Observed a power cord under a doorway that impeded the closing of a corridor door, indicating a life-safety deficiency related to door closures.
    • 42 CFR 483.70(a)Life Safety Code provisions for long term care facilities
    22 Apr 2010Life Safety
    Identified several life-safety deficiencies including gaps around door frames, cords blocking corridor doors, improper signage and emergency lighting, and electrical wiring concerns.
    • Continued From page 1
    • Door protection in corridor openings
    • Exit and directional signs; emergency lighting
    • NFPA 101 Life Safety Code – electrical
    22 Apr 2010Complaint
    An investigation found deficiencies in resident care planning and rights, including inadequate individualized care and concerns about how residents’ dignity was maintained during care activities.
    • Continued From page 1
    22 Apr 2010Licensure
    Determined that the facility was in compliance with state requirements following a survey. No deficiencies were cited.
    30 Dec 2009Complaint
    Found no deficiencies identified during the complaint investigation and determined substantial compliance with participation requirements for long-term care.
    17 Nov 2009Complaint
    Investigated a complaint; no deficient practice identified.
    06 Jul 2009Revisit
    Verified corrections completed for previously reported deficiencies and documented follow-up results.
    • NFPA 101 Life Safety CodeLife Safety Code deficiency
    • NFPA 101 Life Safety CodeLife Safety Code deficiency
    • NFPA 101 Life Safety CodeLife Safety Code deficiency
    • NFPA 101 Life Safety CodeLife Safety Code deficiency
    • NFPA 101 Life Safety CodeLife Safety Code deficiency
    • NFPA 101 Life Safety CodeLife Safety Code deficiency
    02 Jul 2009Revisit
    Verified corrections were completed for deficiencies identified earlier, and noted continued compliance on revisit.
    • 483.15(a)
    • 483.15(f)(1)
    • 483.20(d), 483.20(k)(1)
    • 483.20(k)(3)(i)
    • 483.20(k)(3)(ii)
    • 483.25(c)
    • 483.35(i)
    • 483.75(i)
    • 483.75(i)
    • 483.75(o)(1)
    • 483.65(b)(3)
    21 May 2009Licensure
    Investigated deficiencies identified in care practices, including resident dignity, care planning, and infection control processes. Remarked several failures to meet federal requirements across multiple residents.
    • 483.15(a) DignityDignity
    • 483.20(d)(1) Comprehensive Care PlansComprehensive Care Plans
    21 May 2009Life Safety
    Regulators identified multiple life-safety and maintenance deficiencies during a 2009 survey, including untested fire-drill procedures, deteriorated sprinkler components, and unsafe storage of items near egress.
    • 42 CFR 483.70(a); NFPA 101 Life Safety Code StandardLife Safety Code deficiency
    • NFPA 101 Life Safety Code Standard; 42 CFR 483.70(a)Continued from page 1
    • NFPA 101 Life Safety Code Standard; 42 CFR 483.70(a)Continued from page 2
    • NFPA 101 Life Safety Code Standard; 42 CFR 483.70(a)Continued from page 3
    • NFPA 101 Life Safety Code Standard; 42 CFR 483.70(a)Continued from page 6
    • NFPA 101 Life Safety Code Standard; 42 CFR 483.70(a)Continued from page 5
    • NFPA 101 Life Safety Code Standard; 42 CFR 483.70(a)Continued from page 4
    20 Feb 2009Complaint
    Found no deficiencies identified during the complaint investigation.
    20 Feb 2009Revisit
    Investigated a follow-up for previously identified deficiencies; corrections completed.
    29 Dec 2008Complaint
    Investigated a deficiency where a resident did not receive needed treatment to promote healing and prevent new pressure sores.
    • Pressure ulcers – prevention and treatment
    25 Jun 2007Revisit
    Investigated issues and identified regulatory deficiencies in care and administration; follow-up performed to verify actions.
    01 May 2007Revisit
    Found multiple deficiencies requiring correction and noted corrections completed for cited items.
    • 483.10(b)(4)
    • 483.15(c)(6)
    • 483.25(h)(1)
    • 483.30(a)
    • 483.35(i)(2)
    • 483.60(b), (d), (e)
    • 483.75(d)(1)
    • 483.75(i)(2)
    30 Apr 2007Revisit
    Investigated uncorrected deficiencies; corrections were completed and follow-up confirmed.
    06 Apr 2007Licensure
    Investigated a deficiency found in privacy and confidentiality of resident information; care details and resident identities were discussed in a way that did not protect confidentiality.
    • Privacy and confidentiality of resident information
    07 Mar 2007Complaint
    Identified deficiencies related to resident rights documentation, resident/family participation, and several safety/quality processes evidenced by incomplete advance directives and inadequate consideration of resident input.
    • Type A483.10(b)(4)NOTICE OF RIGHTS AND SERVICES
    • Type A483.15(c)(6)PARTICIPATION IN RESIDENT & FAMILY GROUPS
    05 Mar 2007Life Safety
    Observed life-safety code deficiencies, including unsealed penetrations in a fire-rated barrier and related fire-door requirements, indicating non-compliance.
    • NFPA 101 LIFE SAFETY CODE STANDARDLIFE SAFETY CODE STANDARD
    25 Apr 2006Revisit
    Identified multiple deficiencies tied to CMS regulations; a follow-up verification was conducted to check corrections.
    • 483.15(a)
    • 483.15(h)(2)
    • 483.20(h)
    • 483.25(a)
    • 483.25(b)
    • 483.60(e)
    • 483.65(a)
    • 483.65(h)(2)
    • 483.70(h)
    25 Apr 2006Revisit
    Investigated deficiencies were identified and all cited issues were corrected; subsequent follow-up confirmed corrections completed.
    20 Apr 2006Revisit
    Found multiple deficiencies cited during a post-certification revisit.
    20 Apr 2006Revisit
    Investigated uncorrected deficiencies from a prior visit; several items remained unresolved as of the revisit.
    20 Mar 2006Revisit
    Investigated life safety code deficiencies; corrections were completed and a follow-up visit confirmed compliance.
    • Life Safety Code deficiency
    • Life Safety Code deficiency
    • Life Safety Code deficiency
    • Life Safety Code deficiency
    07 Mar 2006Life Safety
    Identified several life-safety deficiencies related to fire barriers, door closures, and out-of-service life-safety systems.
    • LIFE SAFETY CODE STANDARD
    • LIFE SAFETY CODE STANDARD
    • LIFE SAFETY CODE STANDARD
    • LIFE SAFETY CODE STANDARD
    • LIFE SAFETY CODE STANDARD
    • LIFE SAFETY CODE STANDARD
    • LIFE SAFETY CODE STANDARD
    07 Mar 2006Life Safety
    Found deficiencies in life-safety measures, including doors not resisting smoke, hazardous-area issues, HVAC maintenance concerns, and inadequate outage policies for sprinkler and fire alarm systems.
    • Corridor doors
    • Hazardous areas
    • HVAC Maintenance
    • Policy for sprinkler system outage
    • NFPA 101 Life Safety Code Standard
    • Policy for fire alarm system outage
    25 Jan 2006Licensure
    Investigative findings showed multiple deficiencies in care practices and facility operations, including violations of resident dignity, daily living support, housekeeping, and infection control.
    • Dignity and respect
    • Housekeeping/maintenance
    • Activities of daily living
    • Infection control
    • Sanitation and facilities upkeep
    25 Jan 2006Licensure
    Identified deficiencies in resident dignity and the way care was provided, including observed instances where staff failed to maintain residents' dignity during care.
    • 483.15(a)DIGNITY
    23 Jan 2006Life Safety
    Identified deficiencies in life-safety and fire-protection measures, including sprinkler system maintenance issues, ceiling penetrations, and obstructed or non-functioning door closers.
    • NFPA 13Sprinkler system maintenance and testing
    • NFPA 101 Life Safety CodeCeiling penetrations/ceiling construction
    • NFPA 101 Life Safety Code; NFPA 10 Portable Fire ExtinguishersDoors/Fire doors not functioning; portable extinguishers not maintained
    • NFPA 101 Life Safety CodeCorridor doors and closers
    23 Jan 2006Life Safety
    Life-safety deficiencies were found, including sprinkler system maintenance issues and obstructed door closers.
    • NFPA 13 Section 19.3.6.3; NFPA 101 Life Safety Code StandardSprinkler system maintenance and related code compliance
    03 Jan 2006Life Safety
    Identified life-safety deficiencies including door closers being blocked, unsealed penetrations in ceilings, and improper maintenance or testing of portable fire extinguishers.
    • 42 CFR 483.70(a)Continued From page 1
    • NFPA 10; Table 5-2Continued From page 2
    • NFPA 101 Life Safety CodeContinued From page 3
    • NFPA 101 Life Safety Code StandardContinued From page 3

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