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Location
Worland Healthcare & Rehabilitation Center is located at 1901 Howell Ave, Worland, WY, 82401.
About Worland Healthcare & Rehabilitation Center
Worland Healthcare & Rehabilitation Center is a medium-sized nursing home facility that offers both short-term rehabilitation and long-term care services. With a capacity of 87 beds, the center operates as a for-profit entity, participating in both Medicare and Medicaid programs to ensure accessibility for a wide range of residents. This care home is not part of a continuing care retirement community but is dedicated to serving adults who require skilled nursing care, whether for recovery following hospitalization or ongoing daily assistance with medical and non-medical needs.
The facility focuses on creating a supportive environment for residents who need rehabilitation after events such as strokes, heart attacks, infections, or accidental injuries. Worland Healthcare & Rehabilitation Center supports residents through transitions from hospital stays back to their homes whenever possible. Approximately 44.7% of short-term residents have been able to return home after being discharged from this center, reflecting its role in post-acute recovery and rehabilitation. The center pays close attention to patient safety and health, with reported statistics showing 2.0% of residents having experienced falls resulting in major injuries and 7.1% of short-term stays involving serious infections that required hospitalization. Additionally, 13.8% of short-term residents have needed emergency room care during their stay, highlighting the ongoing medical monitoring and responsive care provided.
King among its care priorities is the maintenance of residents’ independence and quality of daily life. About 77.9% of residents at Worland Healthcare & Rehabilitation Center maintain the ability to engage in activities such as moving, eating, and personal care without assistance, demonstrating the center’s commitment to fostering self-care abilities whenever possible. Nurse staffing averages 3 hours and 51 minutes per resident per day, which reflects the facility’s devotion to hands-on support and medical oversight. The influenza vaccination rate stands at 93.1%, underscoring an established commitment to infection prevention and annual wellness for its residents. Weekend staffing is noted as being below average compared to weekday support, a factor that may influence the consistency of care experiences throughout the week.
The facility is regularly assessed through health, fire, and safety inspections, which review its ongoing adherence to standards for nurturing a safe environment and responding to resident needs. Recent inspections have reported minor issues related to residents’ protection from abuse and neglect, though these have been recognized as involving low potential for harm and affecting few residents. Over the past three years, Worland Healthcare & Rehabilitation Center has been subject to two fines, totaling $3,630, reflecting the diligence of oversight and the continual pursuit of high-quality care.
At Worland Healthcare & Rehabilitation Center, the emphasis remains on providing personalized, round-the-clock care for individuals in need of rehabilitation, skilled nursing, and long-term support. The community’s nursing team and staff strive to deliver compassionate service, tailored to each resident’s health status and daily needs, while abiding by professional standards in a small-town Wyoming setting.
Five Star Senior Living, founded in 1999 and headquartered in Newton, Massachusetts, operates more than 170 communities across the United States, serving over 15,900 residents with nearly 24,000 team members. Now operating as a division of AlerisLife Inc. (Nasdaq: ALR), Five Star has established itself as one of the nation's largest senior living providers and ranks among the top operators of continuing care retirement communities (CCRCs) in the country.
The company provides a comprehensive continuum of care including independent living, assisted living, memory care, skilled nursing, and respite care services. Through strategic partnerships with FOX Rehabilitation for therapy and wellness services, and DispatchHealth for on-demand acute care, Five Star ensures residents have access to comprehensive healthcare solutions without leaving their community. Their innovative Lifestyle360 programming enriches residents' intellectual, physical, emotional, social, and spiritual well-being through daily activities and events tailored to diverse interests and abilities.
Guided by the mission of "honoring and enriching the journey of life, one experience at a time," Five Star embraces a person-directed care philosophy that emphasizes individualized attention and choice-driven services. The name AlerisLife, derived from the Latin "aleris" meaning to "foster, nourish, and develop," reflects their commitment to helping residents pursue new or lifelong goals regardless of age. Their approach centers on the belief that "happy employees mean happy residents," fostering a culture where both staff and residents can thrive.
Five Star's dedication to excellence has earned numerous accolades, including frequent recognition from the Assisted Living Federation of America's "Best of the Best" Awards and the American Health Care Association's Quality Awards. The company has achieved Great Place to Work certification for consecutive years, demonstrating their commitment to both employee satisfaction and resident care. Through evidence-based wellness approaches, fine dining experiences, and warm, inviting environments, Five Star Senior Living continues to set standards for quality senior care across the nation.
People often ask...
Worland Healthcare & Rehabilitation Center offers .
There are 1 photos of Worland Healthcare & Rehabilitation Center on Mirador.
The full address for this community is 1901 Howell Ave, Worland, WY 82401.
No, Worland Healthcare & Rehabilitation Center does not offer respite care.
Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.
Safety & Compliance
In Wyoming, the Department of Health's Healthcare Licensing & Surveys program licenses care facilities and publishes licensure, complaint, and life-safety findings.
License number
nh-219
Facility type
Nursing Home
Inspection Reports
111
Reports
23
Type A Citations
1
Type B Citations
31
Complaints
21
Years
13 May 2025Revisit
13 May 2025Revisit
Verified that previously cited deficiencies were corrected and no new noncompliance was found.
12 May 2025Revisit
12 May 2025Revisit
Verified compliance with emergency preparedness and life safety code requirements after a follow-up visit; all prior deficiencies were corrected.
06 Mar 2025Life Safety
06 Mar 2025Life Safety
Investigated emergency preparedness and life-safety issues; found failures to coordinate with local emergency officials and noncompliant egress doors, hazardous-area protection, and essential electrical system maintenance.
42 CFR 483.73(a)(4)Local, State, Tribal Collaboration Process
NFPA 101, 2012 editionEgress Doors
NFPA 101, 2012 edition, 19.3.2.1.3Hazardous Areas - Enclosure
NFPA 99, 2012 editionElectrical Systems - Essential Electric System
06 Mar 2025Complaint
06 Mar 2025Complaint
Identified violations related to reporting alleged misappropriation of resident funds, activities programming, diet administration, and infection control.
483.12(c)Reporting of Alleged Violations
483.24(c)(1)Activities Meet Interest/Needs
483.60(c)(1)-(7)Menus Meet Resident Nds/Prep in Adv/Followed
483.80(a)Infection Prevention & Control
24 Oct 2024Complaint
24 Oct 2024Complaint
Found that a resident was harmed by another resident due to inadequate protection from abuse, with documented injuries and subsequent actions taken.
CFR 483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
20 Dec 2023Life Safety
20 Dec 2023Life Safety
Found noncompliance with means of egress maintenance and portable fire extinguisher inspection requirements due to ice/snow blocking exits and missing monthly extinguisher inspections.
NFPA 101 2012 edition, 19.2.1; 7.1.10.1Means of Egress Requirements - Other
Determined that no deficiencies were identified in the complaint investigation.
22 Jun 2023Revisit
22 Jun 2023Revisit
Verified prior deficiencies were corrected and no new noncompliance was found.
05 May 2023Complaint
05 May 2023Complaint
Investigated a complaint alleging failure to identify and respond to changes in a resident's condition; found delays in recognizing and communicating health deteriorations, leading to unaddressed symptoms and additional care needs.
42 CFR 483.25Quality of care
27 Dec 2022Revisit
27 Dec 2022Revisit
Verified that all prior deficiencies were corrected and no new noncompliance was found.
13 Dec 2022Revisit
13 Dec 2022Revisit
Verified that all prior deficiencies were corrected and no new noncompliance was found.
27 Oct 2022Licensure
27 Oct 2022Licensure
Found deficiencies in transfer safety practices, meal-time sanitation, and infection control measures. Violations were identified in safety device use during transfers, food-handling hygiene, and wound-care procedures.
CFR 483.25(d)Free of Accident Hazards/Supervision/Devices
CFR 483.80(a)(1)-(2)(4)(e)(f); 483.80(a)(4); 483.80(e)Infection Prevention & Control
27 Oct 2022Life Safety
27 Oct 2022Life Safety
Identified several life-safety deficiencies including obstructed egress, hazardous-area enclosure issues, improper cooking facilities, unmaintained fire alarm systems, and noncompliant corridor doors.
NFPA 101 Life Safety CodeMeans of egress - obstruction
NFPA 101 Life Safety CodeHazardous Areas - Enclosure
NFPA 101 Life Safety Code; NFPA 96Cooking Facilities
NFPA 101 Life Safety CodeFire Alarm System - Testing and Maintenance
NFPA 101 Life Safety CodeCorridor - Doors
27 Oct 2022Licensure
27 Oct 2022Licensure
Concluded that the facility was in compliance with state requirements.
10 Dec 2021Revisit
10 Dec 2021Revisit
Concluded that all prior deficiencies were corrected and no new noncompliance was found.
09 Nov 2021Revisit
09 Nov 2021Revisit
Verified all deficiencies were corrected and compliance was restored after the revisit.
01 Oct 2021Life Safety
01 Oct 2021Life Safety
Found deficiencies in emergency preparedness planning, corridor door hardware, and power-strip use for patient-care equipment.
42 CFR 483.73(a)Emergency preparedness plan reviewed and updated annually
NFPA 101 19.3.6.3.5Corridor doors must be self-latching with positive latching hardware
NFPA 99 10.2.3.6Power strips not used for patient-care equipment (PCREE) in patient care vicinity
30 Sept 2021Licensure
30 Sept 2021Licensure
Investigated nurse staffing postings and infection control practices; found deficiencies in posting accurate staffing data and in wound-care infection control measures.
42 CFR 483.35(g)Nurse Staffing Information
42 CFR 483.80Infection Prevention & Control
30 Sept 2021Licensure
30 Sept 2021Licensure
Found no deficiencies. The survey determined the facility was in compliance with state requirements.
03 Mar 2021Complaint
03 Mar 2021Complaint
Investigated a complaint and a COVID-19 focused infection-control survey conducted in early March 2021. Found no deficiencies identified.
07 Dec 2020Licensure
07 Dec 2020Licensure
Investigated a COVID-19 focused infection control survey and found no deficiencies.
09 Jun 2020Licensure
09 Jun 2020Licensure
Found no deficiencies identified during a COVID-19 focused infection control survey conducted 6/4/20 to 6/9/20.
09 Jun 2020Licensure
09 Jun 2020Licensure
Found no deficiencies identified during a COVID-19-focused infection control survey.
12 May 2020Licensure
12 May 2020Licensure
Investigated a COVID-19 focused infection control survey and found no deficiencies.
11 Mar 2020Complaint
11 Mar 2020Complaint
Investigated a complaint and found a resident was assaulted by another resident, resulting in broken ribs, with care plans not updated to address the behaviors.
CFR 483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
11 Mar 2020Revisit
11 Mar 2020Revisit
Verified that all prior deficiencies were corrected and no new noncompliance was found.
14 Jan 2020Complaint
14 Jan 2020Complaint
Investigated the complaint; found no deficiencies.
20 Sept 2019Revisit
20 Sept 2019Revisit
Verified prior deficiencies were corrected and no new noncompliance was found. All regulations surveyed were met.
10 Sept 2019Revisit
10 Sept 2019Revisit
Verified that all prior deficiencies were corrected and no new noncompliance was found.
01 Aug 2019Licensure
01 Aug 2019Licensure
Identified multiple deficiencies across resident rights, Medicaid notices, grievances, assessments, medications, menus, and food safety.
§483.10(f)(5)-(7)Resident rights - grievances and group/resident/family participation
§483.60(i)(1)-(2)Food safety - Procurement, Storage, Preparation, and Serving
01 Aug 2019Life Safety
01 Aug 2019Life Safety
Investigated issues related to life-safety: problems with means of egress maintenance, incomplete emergency preparedness policies, and hazardous-area protections.
483.73(b)(6)Policies/Procedures - Volunteers and Staffing
2012 NFPA 101 19.2.3.4; 18.2.3.1; 7.1.6Means of Egress - Exterior sidewalk and egress
01 Aug 2019Licensure
01 Aug 2019Licensure
Concluded compliance with state requirements.
24 Jan 2019Revisit
24 Jan 2019Revisit
Concluded that all previously cited deficiencies were corrected and no new noncompliance was found.
05 Dec 2018Complaint
05 Dec 2018Complaint
Investigated a complaint about falls; found failures to report and document unwitnessed falls and to perform appropriate post-fall assessments, leading to potential resident harm.
483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
483.25Quality of care
24 Oct 2018Revisit
24 Oct 2018Revisit
Concluded no deficiencies were found; all prior deficiencies were corrected.
20 Sept 2018Revisit
20 Sept 2018Revisit
Found no deficiencies. A follow-up survey showed prior deficiencies corrected and full compliance with regulations.
09 Aug 2018Complaint
09 Aug 2018Complaint
Found deficiencies in transfer/discharge notification, bed-hold policy, PASARR screenings, and food-service safety practices.
§483.15(c)(5)Contents of the notice
§483.15(d)(1)Bed-hold policy notice
§483.20(k)(1)-(3)PASARR Screening for MD & ID
§483.60(i)(1)-(2)Food safety requirements
09 Aug 2018Licensure
09 Aug 2018Licensure
Found no deficiencies. The survey concluded compliance with State requirements.
08 Aug 2018Life Safety
08 Aug 2018Life Safety
Identified life-safety deficiencies including door egress maintenance problems and inadequate enclosure and coverage for hazardous areas and sprinkler systems.
Type ANFPA 101 Life Safety Code (2012 edition); 18.2.2.2.4; 19.2.2.2.4Egress doors not maintained; ceiling hole observed
Type ANFPA 101 Life Safety Code; Hazardous Areas – EnclosureHazardous areas not properly enclosed/protected
Type ANFPA 25; NFPA 101; 2011/2012 editionsSprinkler system coverage and maintenance for non-required/partial systems
23 May 2018Revisit
23 May 2018Revisit
Verified previous deficiencies were corrected and no new noncompliance was found.
14 Feb 2018Complaint
14 Feb 2018Complaint
Found deficiencies in wound care management and documentation, including missing physician orders and gaps in wound care procedures.
Type ACFR(s): 483.21(b)(3)(i)Care planning and wound management deficiencies
11 Aug 2017Revisit
11 Aug 2017Revisit
Concluded no deficiencies cited in the recent follow-up activity. Noted continued compliance.
04 Aug 2017Revisit
04 Aug 2017Revisit
Verified compliance was restored after follow-up surveys, with full compliance achieved as of August 4, 2017.
29 Jun 2017Life Safety
29 Jun 2017Life Safety
Identified storage next to an electrical panel and insufficient clearance around the panel, creating a potential safety risk during an emergency.
2012 NFPA 101 Life Safety Code; NFPA 70-110.26(A)Clearances around electrical panels
2012 NFPA 101 Life Safety Code; NFPA 70-110.26(A); NFPA 101 Utilities - Gas and ElectricUtilities - Gas and Electric equipment clearance
29 Jun 2017Licensure
29 Jun 2017Licensure
Investigated infection control and sanitation practices; deficiencies found in infection prevention, temperature/vent maintenance, and staff hygiene with corrective actions described.
Identified significant deficiencies in infection control and related resident care practices.
Type A483.60Infection control
01 Sept 2016Licensure
01 Sept 2016Licensure
Found no deficiencies. A survey conducted on 8/29/16 through 9/1/16 determined compliance with state requirements.
30 Aug 2016Life Safety
30 Aug 2016Life Safety
Identified multiple life-safety deficiencies including compromised smoke barriers, missing sprinkler protections, and issues with exit access and door closers.
NFPA 101 Life Safety Code, Section 19.3.2.1Opening around sprinkler head
NFPA 101 Life Safety CodeSmoke barrier compromised
NFPA 101 Life Safety CodeSmoke detector location/distance
NFPA 101 Life Safety Code, Section 9.7.6Locking system did not release upon code entry
NFPA 101 Life Safety Code, Section 9.7.6 and NFPA 13Sprinkler system not installed
NFPA 13Sprinklers in accordance with NFPA 13
NFPA 101 Life Safety CodeOngoing monitoring and corrective actions
30 Aug 2016Life Safety
30 Aug 2016Life Safety
Investigated and found that oxygen storage did not meet requirements; four 40-liter oxygen containers were stored in a one-hour rated room.
2006 IFC, Sec. 105.6.10; 2703.1; 2006 IBC, Sec. 508.3.3Oxygen storage and medical gas storage requirements
08 Jun 2016Complaint
08 Jun 2016Complaint
Identified no deficiencies in the complaint investigation.
18 Dec 2015Revisit
18 Dec 2015Revisit
Verified that previously reported deficiencies were corrected. The revisit confirmed actions completed for identified items.
483.10(b)(4)
483.13(a)
483.13(c)(1)
483.15(b)(1)
483.15(h)(2)
483.20(k)(3)(ii)
483.35(i)
18 Dec 2015Revisit
18 Dec 2015Revisit
Investigated a follow-up visit and found no deficiencies.
12 Oct 2015Revisit
12 Oct 2015Revisit
Investigated and verified correction of deficiencies previously reported; follow-up completed.
12 Oct 2015Revisit
12 Oct 2015Revisit
Verified corrections completed and confirmed no outstanding deficiencies.
20 Aug 2015Licensure
20 Aug 2015Licensure
Found a deficiency in infection-control reporting; an influenza outbreak identified in January 2015 was not reported to the Wyoming Department of Health or Licensing Division.
W.S. 35-4-107Infection control and reporting of infectious diseases/outbreaks
20 Aug 2015Licensure
20 Aug 2015Licensure
Investigated multiple deficiencies related to resident safety, medication administration, and care documentation.
18 Aug 2015Life Safety
18 Aug 2015Life Safety
Investigated deficiencies related to fire safety and emergency lighting, including a door that would not latch and inadequate self-closing/door protection in a smoke compartment, with subsequent repair actions planned or completed.
NFPA 101 Life Safety Code, Section 19.3.2.1Doors kept closed to protect egress corridors
NFPA 101 Life Safety Code, Section 19.3.3.2.1Self-closing doors in smoke compartments
NFPA 101 Life Safety Code, Sections 7.9 and 19.2.9.1Emergency lighting maintenance policy
18 Aug 2015Life Safety
18 Aug 2015Life Safety
Identified deficiencies in oxygen storage separation, inadequate bathroom ventilation, and plumbing code compliance.
IMC Life Safety - Intl Mechanical CodeMechanical ventilation in bath/tub rooms
2006 IPC, Section 416.5, 604.2 and 608.13Plumbing code compliance (IPC)
19 Feb 2015Life Safety
19 Feb 2015Life Safety
Found improper storage of oxidizing gas with an oxygen storage space containing far more than allowed and nearby combustibles.
NFPA 89, Section 5.1.3.3.2(8); IFC Table 2703.1.1(1)State Miscellaneous Life Safety
24 Nov 2014Revisit
24 Nov 2014Revisit
Investigated the follow-up to prior deficiencies and found that corrections were completed.
24 Nov 2014Revisit
24 Nov 2014Revisit
Investigated; post-certification follow-up completed with corrections made and a summary of uncorrected deficiencies sent.
25 Sept 2014Revisit
25 Sept 2014Revisit
Completed corrections for identified deficiencies; follow-up on 09/25/2014 confirmed corrections were completed.
12 Sept 2014Licensure
12 Sept 2014Licensure
Identified deficiencies related to residents' hydration and nutrition, including non-measurable fluid intake goals and outdated care plans for several residents.
—Fluid intake/hydration care plan deficiencies
24 Jul 2014Complaint
24 Jul 2014Complaint
Investigated deficiencies in care planning, infection control, nutrition service, and record-keeping with multiple violations observed.
Type A—Comprehensive Assessments
Type A—Comprehensive Assessments / Care Plan Development
Type A—Admission/Discharge/Transfer
Type A—Food Service Sanitation
Type A—Infection Control
07 Jul 2014Life Safety
07 Jul 2014Life Safety
During inspection, multiple life-safety deficiencies were identified, including issues with smoke barriers, egress doors, and electrical/gas storage practices. Observations showed missing door gasketing, locked egress points, and inadequate documentation for safety testing.
NFPA 101 LIFE SAFETY CODE STANDARDSmoke barriers and door gasketing
NFPA 101 LIFE SAFETY CODE STANDARDSmoke barriers/egress integrity
NFPA 101 LIFE SAFETY CODE STANDARDAccess-controlled egress and door operation
NFPA 101 LIFE SAFETY CODE STANDARD; NFPA 99 (1999) Section 4-3.1.1.2Battery back-up and gas system safety
NFPA 99 (1999); NFPA 101 LIFE SAFETY CODE STANDARDNonflammable gas storage
NFPA 101 LIFE SAFETY CODE STANDARD; NFPA 70 NATIONAL ELECTRICAL CODEElectrical wiring compliance
07 Jul 2014Life Safety
07 Jul 2014Life Safety
Identified multiple life-safety deficiencies, including improper drainage and plumbing-related installations in boiler and janitorial areas.
Type A2006 IPC, Section 802.1State Miscellaneous Life Safety
Type B2006 IPC (International Plumbing Code), vinyl hose requirementsState Miscellaneous Life Safety
WDH Chapter 3 Guidelines; related plumbing codesState Miscellaneous Life Safety
21 Aug 2013Revisit
21 Aug 2013Revisit
Found deficiencies in the emergency power supply and annunciation systems, including an unobservable generator/transfer switch location and absence of an annunciator panel, not meeting NFPA requirements.
NFPA 101 Life Safety Code, 2000 EditionLife Safety Code standard
NFPA 99, 3-4.1.1.15; NFPA 70, NEC 700-12Electrical systems and remote annunciator requirements
21 Aug 2013Revisit
21 Aug 2013Revisit
Identified life-safety code deficiencies related to the emergency power supply and monitoring, requiring corrective actions.
42 CFR 483.70(a)Life Safety Code Standard (NFPA 101)
15 Aug 2013Revisit
15 Aug 2013Revisit
Verified corrections completed for previously cited deficiencies and concluded substantial compliance.
15 Aug 2013Revisit
15 Aug 2013Revisit
Investigated a complaint and noted corrections completed during follow-up.
13 Jun 2013Complaint
13 Jun 2013Complaint
Investigated multiple deficiencies involving mishandled resident care, inadequate assessment and reporting, infection control lapses, and failure to provide required equipment and timely assistance.
—Investigation of allegations and reporting
—Significant change in resident status assessment
—Need for pressure-reducing equipment
—Failure to provide adequate toileting and personal care
—Infection control and personal hygiene
13 Jun 2013Complaint
13 Jun 2013Complaint
Investigated a resident abuse allegation and related deficiencies; identified shortcomings in reporting, investigation follow-up, and care planning with required corrective actions noted.
Type A—Investigation of Allegations and Reporting
13 Jun 2013Licensure
13 Jun 2013Licensure
Investigated the observed issue with resident water temperatures; temperatures exceeded the allowed limit of 110°F.
Wyoming Administrative Code, Chapter 11, Section 6 - Physical EnvironmentPhysical environment standards - resident water temperatures not to exceed 110°F
12 Jun 2013Life Safety
12 Jun 2013Life Safety
Found multiple deficiencies in life-safety and building maintenance, including issues with doors, smoke barriers, sprinkler-related provisions, and storage/housekeeping practices.
NFPA 101 Life Safety Code, 2000 edition; 19.3.2.1Non-sprinklered construction and smoke compartment protections
NFPA 101 Life Safety Code, 2000 edition; 19.3.6.3.2Corridor and door closures to resist smoke
NFPA 101 Life Safety Code, 2000 edition; 19.3.6.3.6 (and related sections)Door construction and closers in corridors
NFPA 101 Life Safety Code, 2000 edition; 19.3.xSmoke barriers and door closures between compartments
NFPA 101 Life Safety Code, 2000 edition; NFPA 701Decorations and fire-retardant fabrics; door closures
NFPA 101 Life Safety Code, 2000 edition; NFPA 99Sprinkler system and alarms; water supply and monitoring
NFPA 101 Life Safety Code, 2000 edition; NFPA 701Decorations and furnishings flame-resistance
NFPA 101 Life Safety Code, 2000 editionTransfer switch panel and generator-related requirements
NFPA 101 Life Safety Code, 2000 edition; NFPA 99Alcohol-based hand rub dispensers and placement
NFPA 101 Life Safety Code, 2000 editionGenerator testing and maintenance
12 Jun 2013Life Safety
12 Jun 2013Life Safety
Investigators identified several life-safety deficiencies, including smoke-resisting corridor doors, placement of hand-rub dispensers, and flame-retardant requirements for curtains and decorations.
19.3.6.3.6Doors protecting corridor openings
—Alcohol-based hand rub (ABHR) dispensers
NFPA 101 Life Safety Code StandardDraperies and curtains (incl. cubicle curtains)
NFPA 101 Life Safety Code StandardWall decorations and coverings
12 Jun 2013Life Safety
12 Jun 2013Life Safety
Multiple life-safety deficiencies were identified, showing non-compliance with NFPA 101 life-safety requirements in several areas, including smoke resistance of corridor doors and the flame retardancy of decorative fabrics and draperies.
NFPA 101 Life Safety Code StandardCorridor doors and smoke barrier/continuity
NFPA 101 Life Safety Code StandardFlame retardant requirements for curtains and draperies
NFPA 101 Life Safety Code StandardDecorations and furnishings flame retardancy
NFPA 101 Life Safety Code StandardAdequate monitoring/alarms for safety systems
NFPA 101 Life Safety Code StandardAdditional life-safety monitoring and equipment
NFPA 101 Life Safety Code StandardAdditional life-safety decorating and equipment standards
NFPA 101 Life Safety Code StandardLife safety standard for furnishings and equipment
20 Jul 2012Revisit
20 Jul 2012Revisit
Verified corrections were completed for deficiencies identified on the prior survey.
483.15(a)
483.15(h)(2)
483.20(b)(2)(i)
483.25(d)
483.20(d)
483.20(k)(1)
483.60(a)(b)
483.20(c)
20 Jul 2012Revisit
20 Jul 2012Revisit
Investigated a revisit to verify corrections of deficiencies cited in a prior CMS-2567; several corrections were completed for life-safety issues.
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
30 May 2012Life Safety
30 May 2012Life Safety
Found several life-safety deficiencies, including issues with sprinkler system installation/maintenance, hazardous-area separation, portable extinguishers, and ongoing monitoring.
NFPA 13Installation and maintenance of automatic sprinkler system
NFPA 101 LIFE SAFETY CODE STANDARDHazardous areas separation
NFPA 101 LIFE SAFETY CODE STANDARDPortable fire extinguishers
—Monitoring and maintenance
—Continued from page 10
24 May 2012Licensure
24 May 2012Licensure
The investigation found deficiencies in housekeeping and maintenance, resident care planning and assessment processes, and other care-related practices, indicating multiple areas needing improvement.
Identified deficiencies in resident assessment, care planning, and nursing standards across multiple residents.
28 Apr 2011Licensure
28 Apr 2011Licensure
Found no deficiencies.
26 Apr 2011Life Safety
26 Apr 2011Life Safety
Investigative findings identified multiple deficiencies related to safety systems, building security, and maintenance practices during a licensing assessment.
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01 Dec 2010Complaint
01 Dec 2010Complaint
Investigated the complaint and found no deficiencies.
17 Jun 2010Revisit
17 Jun 2010Revisit
Investigated and verified that deficiencies previously cited were corrected; follow-up confirmed corrective actions were completed.
483.13(c)(1)(i)(ii)-(iii), (c)(2)-(4)Resident rights
483.20(b)(2)(ii)Resident rights / related requirements
483.20(d), 483.20(k)(1)Resident rights / privacy and belongings
483.25(h)Care planning requirements
483.35(i)Quality of care / professional standards
483.60(b), (d), (e)Administration / governance
11 Jun 2010Revisit
11 Jun 2010Revisit
Verified that previously identified deficiencies were corrected during the follow-up visit.
08 Apr 2010Life Safety
08 Apr 2010Life Safety
Identified multiple life-safety deficiencies, including untested life-safety systems and unsafe electrical conditions, with ongoing maintenance and documentation issues.
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 70 NATIONAL ELECTRICAL CODEElectrical Wiring Standard
NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code Standard
NFPA 101 LIFE SAFETY CODE STANDARDLife Safety Code Standard
08 Apr 2010Complaint
08 Apr 2010Complaint
Investigated deficiencies in care planning and resident safety; observed failures in documentation and adherence to procedures.
08 Apr 2010Licensure
08 Apr 2010Licensure
Concluded no deficiencies were identified during the state licensure survey conducted April 5–8, 2010.
08 May 2009Revisit
08 May 2009Revisit
Identified no deficiencies; all previously observed issues were corrected and verified on follow-up.
30 Apr 2009Revisit
30 Apr 2009Revisit
Identified life-safety code deficiencies during a follow-up visit and noted corrections completed on several items.
12 Mar 2009Licensure
12 Mar 2009Licensure
Identified deficiencies related to residents’ ability to self-administer medications and the interdisciplinary team’s evaluation of those abilities.
483.10(n)Self Administration of Drugs
483.20(d)(2)(ii)Self Administration of Drugs
11 Mar 2009Life Safety
11 Mar 2009Life Safety
Investigated life-safety deficiencies involving smoke barriers, egress walls, and critical building-system testing; found unsealed penetrations and lapses in routine inspections and drills.
NFPA 101 LIFE SAFETY CODE STANDARDSmoke barrier walls not maintained
NFPA 101 LIFE SAFETY CODE STANDARDCorridor walls height/continuity
NFPA 101 LIFE SAFETY CODE STANDARDFire alarm/system testing and drills
NFPA 101 LIFE SAFETY CODE STANDARDEmergency generator testing
NFPA 101 LIFE SAFETY CODE STANDARDGenerator maintenance/testing frequency
06 Jan 2009Complaint
06 Jan 2009Complaint
Investigated a complaint and found no deficiencies.
19 Jul 2007Complaint
19 Jul 2007Complaint
Determined that no deficiencies were identified during the complaint investigation.
29 Jun 2007Complaint
29 Jun 2007Complaint
Investigated a complaint and found no deficiencies.
10 Feb 2006Revisit
10 Feb 2006Revisit
Identified multiple regulatory deficiencies during a follow-up after a prior survey, including life-safety and facility operation requirements.
483.10(b)(11)
483.15(f)(1)
483.25(a)(3)
483.25(d)
483.60(c)(2)
483.65(b)(3)
483.70(h)
483.60(c)(2)
483.75(i)(1)
483.75(i)(1)
483.75(i)(2)
483.25(a)(3)
483.25(d)
10 Feb 2006Revisit
10 Feb 2006Revisit
Investigated a revisit; identified deficiencies requiring corrective actions.
10 Jan 2006Revisit
10 Jan 2006Revisit
Identified life-safety deficiencies related to the Life Safety Code with corrective actions completed.
NFPA 101, Life Safety CodeLife Safety Code deficiency
NFPA 101, Life Safety CodeLife Safety Code deficiency
10 Jan 2006Revisit
10 Jan 2006Revisit
Identified life safety code deficiencies that were corrected by 12/30/2005.
LSC K0017NFPA 101 Life Safety Code – K0017
LSC K0029NFPA 101 Life Safety Code – K0029
01 Dec 2005Licensure
01 Dec 2005Licensure
Identified multiple deficiencies in resident care planning, daily activities, and communication/notification practices, indicating gaps in assessment, planning, and ongoing care.
Type A483.10(b)(11)NOTIFICATION OF CHANGES
Type A483.15(f)(1)ACTIVITIES
Type A483.20(k)(1)COMPREHENSIVE CARE PLANS
Type A—
Type A—
Type A—NURSING SERVICES/CARE
Type A483.25(a)(3)DAILY LIVING ACTIVITIES
01 Dec 2005Licensure
01 Dec 2005Licensure
The agency identified deficiencies in resident care, including failure to notify physicians and families after incidents, and gaps in activities, assessments, and care planning. Several areas showed incomplete or outdated processes affecting residents' wellbeing.
Type A483.10(b)(11)NOTIFICATION OF CHANGES
483.15(f)(1)ACTIVITIES
483.25COMPREHENSIVE CARE PLANS
16 Nov 2005Life Safety
16 Nov 2005Life Safety
The inspection identified several life-safety deficiencies, including improper corridor separation, unsealed penetrations, an inadequately protected corridor door, and clutter that could create a hazardous area.
NFPA 101 Life Safety Code StandardCorridors separated from use areas by fire-rated walls
NFPA 101 Life Safety Code StandardUnsealed cable penetration
NFPA 101 Life Safety Code StandardCorridor door not fire rated or self-closing
NFPA 101 Life Safety Code StandardHazardous area created by clutter
16 Nov 2005Life Safety
16 Nov 2005Life Safety
Identified multiple life-safety deficiencies, including unsealed penetrations and inadequate fire-resistance in corridor walls, requiring corrective action.
—Unsealed cable penetration
NFPA 101 Life Safety Code StandardCorridors separated from use areas by fire-rated walls
NFPA 101 Life Safety Code StandardCorridors separated from use areas by walls with fire resistance
NFPA 101 Life Safety Code StandardLife Safety Code Standard
02 May 2005Complaint
02 May 2005Complaint
Investigated a complaint survey and found no deficiencies.
02 May 2005Revisit
02 May 2005Revisit
Found no deficiencies during the follow-up review.
14 Apr 2005Complaint
14 Apr 2005Complaint
Investigated deficiencies related to resident safety and quality of care, including assessment for removal of side rails and safety of the resident environment.
Type A—Quality of Care
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