Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Optalis Health & Rehabilitation Of Wyoming during CMS and state inspections, most recent first.
A resident with dementia, chronic respiratory failure, and severe protein-calorie malnutrition did not receive timely and thorough assessment and care for a coccyx Stage 2 pressure ulcer. Required weekly skin assessments were not documented for a two-week period, the pressure ulcer was identified without notifying the legal guardian, and a specific care plan was delayed and lacked clear offloading and repositioning interventions. Recommendations for an alternating pressure mattress (APM) and offloading were not promptly implemented, the APM order was significantly delayed, and documentation indicating a turning/repositioning program and pressure-reducing devices did not result in actual interventions. The care plan was not updated when the wound was documented as resolved, and when a subsequent open coccyx area was found, there was no evidence of guardian notification or care plan revision.
A resident with Type 1 DM had a low BG identified, was told by an LPN to eat cookies, and was left without a timely BG recheck or documented ongoing assessment, contrary to the facility’s hypoglycemia policy. Later, the resident was found unresponsive with critically low BG and low O2 saturation, with no documentation that ordered glucagon or supplemental O2 were provided before EMS arrival, despite existing hypoglycemia treatment orders. Two additional residents with Type 2 DM had orders for nightly Lantus with parameters to hold if BG was below a specified level, yet BG checks were either not ordered routinely or not performed and documented on multiple days, while Lantus was still administered without recorded BG values or documented refusals.
Surveyors identified multiple food service and sanitation failures, including lack of hand towels at the only kitchen handwashing sink, a leaking dining room hand sink, and a non-operational cookline hood with filters removed for several days. Resident food in the pantry refrigerator was held beyond the facility’s stated 3-day limit for TCS items, and an expired therapeutic nutrition supplement product was stored with other supplements. Kitchen staff were observed handling clean dishes and resuming food preparation after other tasks or leaving the kitchen without required handwashing, and changing gloves without washing hands. The dish machine’s sanitizing rinse did not reach required temperatures for hot water sanitization, failing to achieve the minimum plate surface temperature needed for effective sanitization.
A resident with an infected hip replacement and impaired mobility reported that a CNA told her to stop using her call light, stated they would not return, then manipulated the bed controls and call light before leaving the room. The resident later awoke needing the bathroom, could not locate the call light, and subsequently had a bowel movement and urinated in bed, leaving her devastated and embarrassed. Another CNA entering after shift change found the resident upset, the bed saturated with urine and feces, and the call light wrapped with the bed remote on the floor, out of the resident’s sight and reach.
Two residents experienced significant clinical changes without provider notification. One resident with type 1 DM had multiple blood glucose readings in the 400–551 range despite an order to notify the physician for values above 200, and there was no documentation that the provider was informed. Another resident with heart disease and a pacemaker reported left-sided chest pain, received nitroglycerin, and had elevated BP and reduced O2 sats documented, but only the spouse was notified and there was no record of provider notification or entry in the provider communication log. The DON confirmed the absence of documentation in both cases.
The facility failed to prevent and monitor misappropriation of medications for two residents when an RN accepted and retained a GLP-1 (Ozempic) from the pharmacy that later could not be located, and only one LPN dispensed all PRN Norco doses to a cognitively intact resident whose pain was controlled with scheduled Tylenol and who reported not requesting the narcotic. Controlled drug records showed a missing Norco tablet that could not be accounted for, and the DON acknowledged that a single nurse exclusively dispensing a narcotic over time appeared suspicious for diversion.
A resident with dementia, anxiety, and bipolar disorder, but assessed as cognitively intact, reported that a CNA yelled at him during a dispute about a roommate’s urinal, and a CNA witness documented that the resident described the aide screaming at him and that he appeared fearful. Although the incident was reported internally and an investigation file and risk management forms were created, the resident’s EHR contained no documentation of the allegation, the verbal altercation, or any related behavioral episodes or psychosocial assessments during the period in question. The DON and NHA confirmed that such allegations were recorded only in internal incident and risk management systems, not in the resident’s medical record, resulting in incomplete and inaccurate documentation contrary to accepted professional standards.
A resident with esophageal cancer and obstruction, receiving enteral nutrition, had their tube feeding paused and restarted by a CNA who was not trained or authorized to perform this task. Interviews with the DON and an LPN confirmed that only trained staff should handle tube feedings, but it was reported that CNAs regularly performed this action, contrary to facility policy.
The facility failed to ensure call lights were within reach for residents, compromising their ability to alert staff for assistance. A resident with dementia and mobility issues was repeatedly observed with her call light on the floor, out of reach. Another resident was unaware of the call light's location due to it being hooked through the bed frame. A CNA confirmed that staff should check call light placement, indicating a lapse in protocol adherence.
A facility failed to adhere to professional standards for medication administration for a resident with a seizure disorder. The resident was prescribed Vimpat 50 mg twice daily, but the medication ran out on January 12, 2025, and was not available until January 16, 2025. Despite this, the Emar showed a dose was given on January 14, 2025, which was not accounted for in the Control Substance Record. The Unit Manager confirmed the medication was not available, indicating a failure to maintain accurate documentation.
The facility failed to implement Enhanced Barrier Precautions and Contact-Based Precautions for three residents, leading to infection control deficiencies. Nurses did not follow gown requirements, and Contact Precautions were delayed for two residents. Additionally, IV administration protocols were not followed for a resident, risking infection. The facility also neglected its water management plan, failing to address abnormal legionella levels, potentially affecting all residents.
A resident self-administered a nebulizer treatment without proper assessment or supervision, as the facility failed to perform necessary assessments and obtain a physician order for self-administration. The resident had diagnoses including pneumonitis and COPD, and the facility's policy requires an interdisciplinary team assessment for self-administration, which was not conducted. An LPN acknowledged the need for supervision during treatments but cited time constraints as a barrier.
A facility failed to monitor and assess the use of psychotropic medications for a resident with schizoaffective disorder, bipolar disorder, and PTSD. Despite a care plan requiring medication monitoring, there was no documentation of monitoring for side effects or effectiveness. An LPN confirmed the absence of documentation, highlighting a failure to follow the facility's policy on psychoactive drug use.
The facility failed to label and date medications, dispose of expired medications, and secure medication carts. An insulin pen was improperly stored, and several medications lacked proper labeling. Personal belongings were found in a medication room, and medication carts were left unlocked and unattended. These issues indicate deficiencies in medication management practices.
The facility failed to provide coordinated hospice care for two residents, resulting in a lack of collaborative care. One resident with multiple sclerosis was unaware of the hospice staff's visit schedule, and there was no documentation of hospice participation in care conferences. Another resident with hemiplegia reported severe pain, and the RN was unaware of the hospice staff's visit schedule. The facility's social worker could not locate documentation of hospice participation in care conferences, and the last hospice records were dated over a week prior.
A resident with heart disease and hypertension was not administered the pneumococcal vaccine PCV20 upon admission, despite being due and having consented. The resident's immunization status remained pending, and the DON acknowledged the oversight, noting a lack of process to ensure timely vaccination. Facility policy required offering the vaccine upon admission unless contraindicated or previously vaccinated.
Failure to Provide Timely and Effective Pressure Ulcer Assessment and Care
Penalty
Summary
The deficiency involves the facility’s failure to provide thorough and effective quality care to treat and prevent recurrence of a pressure sore for one resident. The resident was admitted with chronic respiratory failure, dementia, and severe protein-calorie malnutrition, and was assessed as moderately cognitively impaired with a legal guardian for medical decisions. Although an RN stated that weekly full-body skin assessments were conducted on all residents, the EMR showed no skin assessments for this resident over a two-week period. A Stage 2 pressure sore on the coccyx was first documented on 3/10/2026, but the note did not show that the legal guardian was notified. When a medical provider evaluated the resident two days later, the wound had increased in size, and recommendations were made for an alternating pressure mattress (APM) and offloading. A care plan specific to the Stage 2 pressure ulcer was not initiated until nine days after the wound was identified, and the plan lacked actionable interventions for offloading or a defined repositioning regimen. The care plan referenced a prior refusal of an APM in 2024 and a plan to reattempt, but there was no documentation of when or whether this reattempt occurred. A 3/19/2026 progress note, generated from a check-box form, indicated a turning/repositioning program and pressure-reducing devices for bed and chair, but the DON reported this documentation did not translate into implemented actions. A physician order for an APM was not entered until twelve days after the provider’s recommendation. The EMR later documented that the skin issue was resolved, but the care plan was not updated to reflect resolution, and there was no documentation of assessments or care plan changes to prevent recurrence. A subsequent total body skin evaluation documented another open, measurable coccyx area without evidence that the guardian was notified or that the care plan was revised as of 4/7/2026.
Failure to Competently Manage Hypoglycemia and Follow Insulin Parameters for Diabetic Residents
Penalty
Summary
The deficiency involves failures in recognizing and managing hypoglycemia and in administering insulin according to physician orders for three diabetic residents. One resident with Type 1 diabetes had orders for blood glucose (BG) checks before meals and at bedtime, with specific hypoglycemia treatment orders including oral glucose tablets and glucagon nasal spray. On the morning in question, an LPN obtained a BG of 69 mg/dL, documented only in a nursing note, encouraged the resident to eat cookies, and then left the room without rechecking the BG or reassessing the resident as required by the facility’s hypoglycemia policy. There was no documentation of a repeat BG within approximately 15 minutes, no documentation that the resident’s clinical status was monitored during this period, and no documentation that the resident was medically stable until vital signs were taken about 1 hour and 45 minutes later. When the resident was next assessed, vital signs showed an oxygen saturation of 84% on room air and a BG of 46 mg/dL. Documentation and interviews indicate the resident was unresponsive at that time, with a critically low BG and elevated blood pressure. Staff did not document application of supplemental oxygen after the low oxygen saturation was identified, and there is no documentation that ordered emergency hypoglycemia treatments (glucagon) were administered by facility staff prior to EMS arrival. EMS and hospital records reflect that staff reported the resident’s sugar had been found low earlier, that the resident had been told to eat and left alone, and that staff stated they did not have glucagon or glucose to give, despite existing orders for oral glucose tablets and glucagon nasal spray. EMS found the resident unresponsive, hypoxic, and with a BG of 24 mg/dL, and administered glucagon. The deficiency also includes failures to follow physician orders for insulin administration parameters for two other residents with diabetes. One resident with Type 2 diabetes had an order for nightly Lantus insulin with instructions to hold the dose if BG was less than 100 mg/dL, and to obtain a BG prior to administration. Review of records showed multiple dates on which no BG was assessed in the evening, yet all Lantus doses were documented as given, with no rationale or documentation of BG refusals. Another resident with Type 2 diabetes had an order for nightly Lantus with instructions to hold if BG was less than 100 mg/dL, but there was no corresponding order for routine BG assessments. Over a several-week period, only four BG readings were documented, while Lantus was administered on most nights, including nights without a recorded BG. The DON confirmed that BGs were not consistently obtained prior to insulin administration and that nurses were expected to review full order summaries to follow provider-ordered parameters.
Multiple Food Service Sanitation and Hand Hygiene Failures in Kitchen and Dining Areas
Penalty
Summary
The deficiency involves multiple failures in kitchen sanitation and food handling practices observed during a survey. Surveyors observed that the only designated handwashing sink in the dishwashing room did not have hand towels readily available, contrary to FDA Food Code requirements for hand drying provisions. In the dining room, the hand sink was leaking cold water, and the dietitian reported that the faucet had been repaired the prior week for the same issue, indicating the plumbing system was not maintained in good repair. Additional observations showed that the ventilation hood system over the cookline was not properly maintained. Filters were missing from the face of the hood ventilation system, and the dietitian stated the filters had been out for cleaning since several days prior and that the hood was not operational, then turned the hood off. This condition did not meet FDA Food Code requirements that ventilation hood systems be sufficient in number and capacity to prevent grease or condensation from collecting on walls and ceilings. Surveyors also identified improper food storage, expired products, and inadequate hand hygiene and dish sanitization practices. Resident food stored in the pantry refrigerator included a foam takeout container with an orange/brown sauce dated beyond the facility’s stated 3-day holding policy for time/temperature controlled for safety food. A Vital therapeutic nutrition supplement with an expiration date already passed was found on shelving with other therapeutic nutrition products. Kitchen personnel were observed handling clean dishes after other tasks without washing their hands, removing gloves and donning new ones without handwashing, and leaving and re-entering the kitchen to resume food preparation without washing hands, contrary to FDA Food Code handwashing requirements. The dish machine’s sanitizing rinse failed to reach the required 180°F at the gauge and 160°F plate surface temperature, with a DishTemp plate registering only 146°F, which did not meet FDA Food Code standards for hot water sanitization temperatures.
Failure to Maintain Resident Dignity and Access to Call Light
Penalty
Summary
The deficiency involves the facility’s failure to treat a resident in a dignified manner and to honor her rights to self-determination and communication. The resident was an adult female admitted with an infected right hip replacement and difficulty walking. In an interview, she reported that very early one morning a CNA entered her room and told her to stop using her call light, stating that the CNA had already been in the room multiple times and would not be coming back again. The resident stated that the CNA then manipulated her bed controls and call light and left the room. The resident later awoke around 5:00 AM needing to use the bathroom and was unable to locate her call light to request assistance. According to the resident, because she could not find the call light, she had a bowel movement and urinated in her undergarments, which left her feeling devastated and embarrassed. Another CNA, who entered the room after shift change that morning, reported smelling feces, finding the resident very upset, and observing that the sheets were saturated with urine and feces. This CNA also reported that the call light was wrapped together with the bed remote, on the floor, out of the resident’s sight and reach. The CNA implicated in the incident was no longer employed at the facility and was not available for interview.
Failure to Notify Providers of Significant Changes and Abnormal Clinical Findings
Penalty
Summary
The deficiency involves the facility’s failure to notify providers of significant changes in condition and abnormal clinical findings for two residents. One resident with type 1 diabetes mellitus and an order to obtain blood sugars before meals and at bedtime, with instructions to notify the physician for blood glucose levels less than 60 or greater than 200, had multiple documented blood sugar readings far above the ordered threshold. These included values in the 400–551 range on numerous dates. Review of the electronic medical record showed no documentation that the provider was notified of any of these elevated blood sugar results. When surveyors requested evidence of provider notification, the Nursing Home Administrator acknowledged there was no documentation, and the DON stated that the expectation was for licensed nurses to notify the provider of elevated blood sugars, typically when readings were greater than 450. The second resident, who had heart disease and a cardiac pacemaker, experienced an episode of left-sided chest pain for which nitroglycerin was administered. Vital signs at that time included a blood pressure of 158/90, pulse 73, respirations 18, temperature 97.3, and oxygen saturation of 93% on room air. Nursing documentation indicated that the nurse notified the resident’s wife of the condition and that she advised continued monitoring and possible hospital transfer if the condition worsened. However, there was no documentation in the electronic medical record or provider communication log that the provider was notified of this chest pain episode, despite the resident’s complex cardiac history. The DON confirmed there was no documentation of provider notification. The report cites a nursing textbook outlining failure to communicate abnormal assessment data or significant changes in status as a common negligent act.
Failure to Prevent and Monitor Misappropriation of Medications
Penalty
Summary
The facility failed to prevent misappropriation of a resident’s medication when a nurse accepted and retained possession of a GLP-1 medication (Ozempic) for a male resident with type 2 diabetes and the medication subsequently could not be located. According to the facility-reported incident, the RN accepted the Ozempic from the pharmacy late at night and had it in her possession, then attempted to obtain a co-signature from an LPN after she already had the medication. The LPN found this concerning and reported it to the DON early the next morning. When first shift staff arrived, the Ozempic could not be found, and the packing slips for all medications delivered were recovered except for the Ozempic. Multiple co-workers reported that the RN frequently communicated or inquired about medications for weight loss. The facility also failed to adequately monitor and investigate potential or ongoing misappropriation of a resident’s narcotic medication when only one LPN dispensed all doses of a PRN narcotic (Norco) to a cognitively intact female resident over an extended period, and a missing tablet was documented without resolution. Review of the controlled drug records showed that from late October to early January, only one nurse dispensed the Norco, and an entry indicated a correct count had been completed but one tablet was missing and could not be accounted for. The resident reported that her pain was effectively controlled with scheduled Tylenol at night and that she did not request the PRN Norco. The DON confirmed that the pattern of only one nurse dispensing the narcotic appeared suspicious for diversion, and the NHA confirmed the resident’s report that she did not require the PRN Norco for pain control.
Failure to Document Resident Abuse Allegation and Related Assessments in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a cognitively intact resident with multiple psychiatric diagnoses, including dementia with agitation and psychotic disturbance, anxiety, and bipolar disorder. The resident’s admission record and MDS showed he was cognitively intact, with a BIMS score of 15. On or around late September, the resident reported to staff that a CNA had yelled at him when he complained about his roommate’s urinal being left in the bathroom, and he stated that the interaction was upsetting to him. In a typed interview statement, the resident reported that the aide spoke to him in a way he did not like, but he did not remember the aide’s name and stated he was not scared and felt safe in the facility. A CNA’s written statement documented that the resident described arguing with a specific CNA about the urinal being left in the bathroom, that he had removed it and thrown it on the floor, and that the CNA was screaming at him until an RN intervened. The CNA also documented that the resident appeared fearful and stated he would protect himself from the aide if necessary, and that she immediately reported the incident to the facility abuse coordinator. Despite these reports and the internal investigation, a review of the resident’s electronic medical record for the period surrounding the alleged incident showed no documentation of the resident’s complaint, the alleged verbal altercation, or any related behavioral episodes such as yelling or verbal aggression by either the resident or staff. Interviews with the DON and NHA confirmed that allegations of staff yelling or swearing at residents were documented only in the facility’s incident reporting system and on internal risk management forms, which are not part of the resident’s medical record. The DON stated she was unsure whether such accusations would be documented in the resident’s progress notes and indicated that staff would definitely document if a resident yelled or swore at staff, but not necessarily if staff were accused of yelling at a resident. The NHA stated that the facility did not document the resident’s initial accusation in the medical record and that related information was kept in an investigative file separate from the record. This practice resulted in the absence of any documentation in the resident’s electronic medical record regarding the allegation, the resident’s psychosocial status, or any follow-up assessments during the relevant time frame, contrary to accepted professional standards for nursing documentation as described by the American Nurses Association.
Untrained Staff Paused and Restarted Enteral Feeding
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) paused and restarted enteral tube feeding for a resident diagnosed with esophageal cancer and esophageal obstruction, who was receiving enteral nutrition per physician's orders. The CNA reported pausing the tube feeding prior to providing care and then restarting it afterward, despite not being trained or authorized to perform this task. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed that only trained staff, such as licensed nurses and med techs, were permitted to pause and restart tube feedings. Additional staff interviews revealed that CNAs regularly performed this action, indicating a lack of adherence to facility policy regarding tube feeding management.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for residents, which is a critical aspect of accommodating their needs and preferences. Resident #305, a female with dementia, unsteadiness, cognitive communication deficit, and lack of coordination, was observed multiple times with her call light on the floor, out of sight and reach. Despite requiring assistance for daily activities, she stated she would manage on her own, indicating a lack of awareness or ability to use the call light effectively. Observations on consecutive days showed the call light consistently out of reach, whether she was in bed or in a wheelchair. Another resident in bed 104-A was also found with the call light cord hooked through the bed frame, leaving the call light on the floor and inaccessible. This resident was awake and watching television but was unaware of the call light's location when asked. A CNA confirmed that staff are expected to check call light placement each time they enter a room, suggesting a lapse in adherence to this protocol. These observations highlight a failure in ensuring residents can alert staff when needed, compromising their ability to receive timely assistance.
Medication Administration Discrepancy for Resident with Seizure Disorder
Penalty
Summary
The facility failed to adhere to professional standards for medication administration for a resident with a seizure disorder. The resident, a male with a history of seizure disorder, frequent falls, weakness, and unsteadiness, was prescribed Vimpat (Lacosamide) 50 mg twice daily. A review of the Control Substance Record indicated that the medication was last administered on the morning of January 12, 2025, and had run out, with no additional pills available until January 16, 2025. Despite this, the Electronic Medication Administration Record (Emar) showed that the resident was given a dose of Vimpat on the evening of January 14, 2025, which was not accounted for in the Control Substance Record. During an interview, the Unit Manager confirmed that the Vimpat was not available in the facility on the evening of January 14, 2025, and could not explain why it was recorded as administered. This discrepancy indicates a failure to maintain accurate and complete documentation of medication administration, as required by professional standards. The report highlights the importance of ensuring that medication records are truthful and complete to maintain the quality of care for residents.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and Contact-Based Precautions for three residents, leading to deficiencies in infection control. One resident, who was cognitively intact and required extensive assistance, had a sign on their door indicating the need for EBP, including wearing gloves and a gown. However, two nurses entered the room with only gloves, disregarding the gown requirement. Another resident, admitted with a wound infection and paraplegia, was placed on EBP but did not have Contact Precautions implemented until over six weeks later, despite a physician's order. Similarly, a third resident with sepsis was not placed on Contact Precautions until 25 days after admission, despite being on EBP. The facility also failed to follow policies and procedures for IV administration for one resident. During an observation, a nurse was seen using undated tubing for an IV antibiotic and did not disinfect the port before reconnecting the tubing. The nurse admitted to not having an answer for why the port was not cleaned and mentioned a lack of tubing as a reason for the improper practice. This failure to adhere to IV administration protocols posed a risk of infection for the resident. Additionally, the facility did not implement its water management plan to reduce the risk of legionella and other pathogens, potentially affecting all residents. A water analysis revealed abnormal levels of legionella, but the facility did not take the required remedial actions, such as enhanced monitoring or notifying the Regional Director of Maintenance. The Director of Maintenance admitted to not being familiar with the entire water management plan, and housekeeping staff were not properly instructed to flush sinks, as required by the plan.
Failure to Assess and Supervise Self-Administration of Medication
Penalty
Summary
The facility failed to perform a resident assessment and obtain a physician order for the self-administration of a breathing treatment for a resident, resulting in the resident self-administering a nebulizer treatment without appropriate supervision and assessments. The resident, identified as R225, was admitted to the facility with diagnoses including pneumonitis, heart disease, lack of coordination, and blindness in one eye. During an observation, it was noted that R225 was in his room starting a breathing treatment without being assessed by the registered nurse (RN) present, who also did not perform a post-assessment after the treatment was completed. The Medication Administration Record (MAR) indicated an order for Arformoterol Tartrate Inhalation Nebulization Solution to be administered twice daily for COPD. However, there were no orders, assessments, or care plans for the self-administration of medications in the resident's electronic medical record. The facility's policy on self-administration of medications requires an interdisciplinary team assessment and periodic re-evaluation, which was not conducted for R225. Additionally, a Licensed Practical Nurse (LPN) admitted that nurses are supposed to stay with residents during nebulizer treatments but cited time constraints as a reason for not doing so.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor and assess the use of psychotropic medications for a resident identified as R19. The resident, who was admitted with diagnoses of schizoaffective disorder, bipolar disorder, and PTSD, was observed to be tearful and intermittently crying during an interview. The care plan for R19 included administering medications as ordered and monitoring for side effects and effectiveness, yet there was no documentation of such monitoring in the medical records. A behavioral health document indicated that hydroxyzine was discontinued, and the plan was to monitor for changes in mood or behaviors for 14 days, but this monitoring was not documented. During an interview, an LPN confirmed that there was no documentation in the MAR for monitoring R19's behaviors or side effects of psychotropic medications, although such monitoring was documented for another resident. This lack of documentation and monitoring represents a failure to adhere to the facility's policy on psychoactive drug use, which aims to prevent excessive dosing, duration, and ensure adequate monitoring and indications for use.
Medication Management Deficiencies
Penalty
Summary
The facility failed to properly label and date mark opened medications, dispose of expired medications, and secure medication carts. During an observation of a medication cart on the 100 hall, it was found that a Flex Touch 1000 insulin pen, which should have been refrigerated until opened, was improperly stored in the cart. Additionally, a vial of Lantus insulin, two bottles of Systane eye drops, Polymyxin antibiotic eye drops, and Dorzolamide/Timol eye drops were not labeled with the resident's name or the date they were opened. A registered nurse confirmed these labeling issues and acknowledged that the insulin pen should have been refrigerated. Furthermore, a personal belonging, specifically a large black purse, was found stored in a medication room, which was confirmed by the unit manager to be inappropriate. The facility's Medication Access and Storage Policy, adopted on 7/11/2018, did not address the labeling of medications, which contributed to the deficiencies observed. Additionally, during separate observations, two medication carts were found unlocked and unattended in the hallways. In one instance, an LPN admitted to forgetting to lock the cart, and in another, a medication treatment cart was left unlocked with no nurses in view. The LPN responsible for the cart confirmed that it should have been locked when unattended. These lapses in securing medication carts and improper labeling and storage of medications highlight significant deficiencies in the facility's medication management practices.
Lack of Coordinated Hospice Care for Two Residents
Penalty
Summary
The facility failed to provide coordinated hospice care for two residents, resulting in a lack of collaborative care. Resident R16, a female with multiple sclerosis and neuromuscular dysfunction, was observed to be unaware of the hospice staff's visit schedule, except for a hospice aide who visited on Wednesdays without a set time. The facility's social worker could not find documentation confirming hospice participation in R16's care conferences, and there was no record of weekly hospice visits in her electronic medical records. An email request for hospice records revealed that the hospice aide provided weekly showers, but it was unclear if other services were provided. Resident R41, a female with hemiplegia, dysphagia, and chronic kidney disease, reported severe stomach pain and was receiving Tylenol for pain management. The RN was unaware of the hospice staff's visit schedule for R41. The facility's social worker could not locate documentation of hospice participation in R41's care conferences, and the last hospice records were dated over a week prior. Progress notes indicated that R41 experienced severe pain and nausea, but there was no indication of hospice notification regarding her condition change. The facility's NHA found documentation that R41 refused hospice nurse aide services, but there was no explanation for the lack of hospice nurse documentation in her medical record.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer the pneumococcal vaccine to a resident, identified as Resident #29, who was reviewed for immunizations. Upon admission, the resident had pertinent diagnoses including heart disease and hypertension and was due for the pneumococcal vaccine PCV20. The Michigan Care Improvement Registry indicated that the resident was due for this vaccine since admission, and the resident had consented to receive it. However, the resident's electronic health record showed the pneumococcal status as pending. The Director of Nursing acknowledged that the vaccine was due upon admission and should have been scheduled by the unit manager, but this did not occur. Additionally, there was uncertainty about whether the Infection Preventionist had a process to ensure timely offering of pneumococcal vaccines to residents. The facility's policy stated that all residents should be offered pneumococcal vaccines upon admission unless contraindicated or previously vaccinated.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wyoming
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harbor Post Acute Center | 1.2 mi | — | 11 | 0 |
| Corewell Health Rehabilitation & Nursing Center - | 2.9 mi | — | 7 | 0 |
| Optalis Health And Rehabilitation Of Grand Rapids | 3.1 mi | — | 21 | 2 |
| Medilodge Of Wyoming | 3.8 mi | — | 0 | 0 |
| Beacon Hill At Eastgate | 3.8 mi | — | 2 | 0 |
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