Polaris Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cheyenne, Wyoming.
- Location
- 2700 E 12th Street, Cheyenne, Wyoming 82001
- CMS Provider Number
- 535025
- Inspections on file
- 37
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 33
Citation history
Health deficiencies cited at Polaris Rehabilitation And Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility’s 2026 facility-wide assessment, completed with a census of 69 residents, listed only total full-time employees and did not evaluate resident acuity or define specific staffing needs for each shift for RNs, LPNs, MA-Cs, and CNAs. In an interview, the administrator acknowledged that the assessment did not include shift-specific staffing requirements and stated he believed the assessment met regulatory requirements.
The facility failed to honor resident food preferences and provide adequate alternative meal options. During multiple observed meals, residents were not offered substitutes, and staff told them requested items were not on the menu. Meal slips showed that a resident’s written requests for extra yogurt and cottage cheese were limited or marked as not approved per the administrator, and another resident’s request for a double turkey and cheese sandwich was denied. Resident council minutes documented concerns about reduced food items such as burger vegetables, PB&J evening snacks, and daily ice cream, with no evidence of follow‑up. Several residents reported hamburgers without condiments and sandwiches with very little meat or cheese, stating that if an item was not on the menu, it was not provided. Nursing staff, CNAs, and kitchen staff reported that the administrator had reduced yogurt and cottage cheese availability, removed various commercial snacks, cut back food ordering, and restricted what residents could have, while there was no dietary manager and a newly hired dietitian had not yet evaluated residents or meals, contrary to the facility’s own nutritional management policy.
Two residents, both cognitively intact but with mobility limitations, were involved in a physical altercation in their shared room, resulting in injuries including a swollen jaw, hematoma, head abrasion, and a fractured hand. The incident was preceded by reports of fear and prior aggression, and staff responded to a commotion, finding one resident on the floor and both holding a walker. Both residents required hospital evaluation, and one was later transferred due to a blood infection and subsequently passed away.
A resident with severe cognitive impairment experienced a significant decline in functional status after the facility failed to discontinue valproic acid as ordered by a neurologist, resulting in continued administration of multiple sedating medications. Despite clear hospital discharge instructions and family requests, the facility continued unnecessary medications, leading to the resident’s decline from independent mobility to total dependence.
The facility did not provide enough nursing staff to meet the daily needs of all residents, resulting in delayed assistance with meals, bathing, toileting, and other ADLs. Residents with high care needs experienced long waits for help, missed showers, and inadequate supervision during meals. Staff interviews confirmed that staffing levels were insufficient, leading to incomplete care, increased stress, and reliance on non-nursing staff to fill gaps.
Surveyors identified deficiencies when two residents were not treated with dignity and respect. One resident, who was severely cognitively impaired and dependent on staff, experienced long delays before being served meals and was left unattended in the dining room, with only one CNA assigned to assist multiple residents. Another resident, who had hoarding behaviors, became upset after staff entered their room without consent while they were hospitalized and removed items belonging to the facility. Staff interviews confirmed inadequate staffing during meals and that the room entry was directed by the NHA.
A resident with multiple medical conditions and moderate cognitive impairment was placed on a mechanical soft chopped diet following a speech language pathology evaluation, but the resident's representative was not notified of this change as required by facility policy. Both the resident and family expressed confusion about the diet, and the NHA confirmed the lack of notification.
Two residents who required assistance with activities of daily living did not receive routine bathing as care planned. One resident, severely cognitively impaired and fully dependent, received only two baths in over three weeks, while another, who was care planned for twice-weekly showers and sometimes resisted care, received only one bed bath with no documented refusals. Documentation and interviews confirmed the lack of routine bathing and insufficient recordkeeping.
The facility did not consistently implement or monitor pressure ulcer prevention interventions for two residents at risk, resulting in the development of new pressure ulcers. In both cases, care plans called for regular skin checks and use of pressure-reducing devices, but lapses in staff practices, incomplete assessments, and inconsistent use of preventive equipment led to the identification of new wounds, including a stage 3 pressure ulcer.
Two residents did not receive timely incontinence care, including one who was left in a wet brief for approximately six hours and another who waited about an hour for assistance with a bedpan and did not receive pericare. Both incidents involved delays in staff response and unmet care needs.
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on each shift, as required.
Multiple residents with significant physical and cognitive impairments did not receive routine bathing or personal hygiene assistance for extended periods, as confirmed by interviews, medical records, and grievance forms. Residents reported missed showers and delayed care, often attributed by staff to ongoing staffing shortages, with some residents going weeks without bathing and having to escalate their requests to facility leadership.
The facility did not include the total hours worked by RNs, LPNs, and CNAs on daily nurse staffing postings, as required. Staff postings only listed individual names, positions, and hours worked, but omitted the total hours for each staff category. This was confirmed by the administrator during staff interviews.
A resident with complex medical needs received a new fentanyl patch without removal of the previous one, leading to simultaneous exposure to two patches. This medication error resulted in a change in the resident's level of consciousness and required hospitalization in the ICU for an accidental opiate overdose, where the resident was treated with IV Narcan.
A resident with severe cognitive impairment was physically assaulted by another resident experiencing acute delusions and agitation, resulting in mild injury before staff intervened. The facility failed to prevent the abusive event, which violated the resident's right to be free from physical abuse.
The facility failed to document SARS-CoV-2 test results for residents and staff during a COVID-19 outbreak. Despite ongoing testing and screening, results were not consistently recorded, and the former infection preventionist had resigned. The facility's guidelines required testing until no new cases for 14 days, but documentation was incomplete.
The facility failed to communicate changes in healthcare appointments to residents or their representatives, affecting two residents. One resident's urology appointment was rescheduled without notifying the representative, and another resident's follow-up appointment was canceled without rescheduling or documentation. The DON was unaware of the communication process for appointment changes.
A resident with a tracheostomy did not receive adequate care as required, with multiple omissions in the treatment administration record. The resident reported delays in dressing changes and cannula cleaning. Staff interviews indicated occasional care refusals by the resident, but these were not documented as per facility policy. The Director of Nursing confirmed the lack of documentation or care provision, and the administrator acknowledged the absence of documented competency for the involved nurses.
The facility failed to document communication with the dialysis center for three residents receiving dialysis services. A resident scheduled for dialysis on specific days had missing documentation for several treatments. Another resident also had missing records for multiple treatments, and a third resident lacked documentation for one treatment. An RN indicated that the facility had stopped using dialysis binders to track these communications.
A facility failed to develop a complete baseline care plan for a newly admitted resident with stage 5 chronic kidney disease and dependence on dialysis. The care plan, created shortly after admission, omitted the focus area of dialysis, a critical aspect of the resident's care. This omission was confirmed by the DON.
A facility failed to update a care plan for a resident with severe cognitive impairment who smoked regularly. Despite a safe smoking assessment requiring a smoking apron, the care plan lacked goals and interventions for tobacco use. The DON confirmed the oversight, which violated the facility's policy requiring documentation of safe smoking measures in care plans.
A facility failed to conduct a safe smoking assessment for a resident who began smoking after admission, despite being initially assessed as a non-smoker. The resident was observed smoking under staff supervision, but no updated assessment was completed, contrary to facility policy. The DON confirmed the oversight, highlighting a deficiency in ensuring a safe environment.
A resident did not receive the pneumococcal immunization as per CDC guidelines. The resident had previously received the Prevnar 23 vaccine and consented to the PCV20 vaccine, but it was not administered due to an oversight. The facility's policy aligns with CDC recommendations, which state that individuals 65 or older who have only received the PPSV23 vaccine should receive either the PCV15 or PCV20 at least one year later.
The facility did not update the daily staff posting for three days, as observed on a Sunday. The posting was eventually updated later that day. The scheduler, responsible for the updates, did not work weekends and was unaware of who should update the posting during that time. The DON stated it was the manager on duty's responsibility to update the posting on weekends.
Failure to Include Shift-Specific Staffing and Acuity in Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a comprehensive facility-wide assessment that considered specific staffing needs for each shift in order to care for residents competently during routine operations and emergencies. The facility assessment dated 1/5/26 for the 2026 year, with a census of 69 residents, listed only the total number of full-time employees and did not include an evaluation of resident acuity or delineate required staffing levels by shift (day, evening, night) for RNs, LPNs, MA-Cs, and CNAs. During an interview on 4/22/26 at 3:40 PM, the administrator confirmed that specific staffing needs by shift were not included in the assessment and stated that he believed he had completed the facility assessment in accordance with requirements. No additional resident-specific clinical details or medical histories were provided in the report, and the findings focus solely on the omission of shift-specific staffing analysis and resident acuity considerations in the facility’s assessment documentation.
Failure to Honor Food Preferences and Provide Adequate Alternatives
Penalty
Summary
The deficiency involves the facility’s failure to provide nourishing, palatable, well‑balanced diets that considered resident preferences and honored reasonable food requests. During three separate meal observations, residents were not offered substitute meal items, and when alternatives were requested, staff told residents the requested foods were not on the menu. Meal slips for one resident showed repeated written requests for additional yogurt and cottage cheese that were either limited by direction of the administrator or marked as “Not Approved” or “Not on Menu.” Another resident’s meal ticket documented a request for two turkey and cheddar sandwiches, with a notation at the bottom stating “No Double Sandwiches” per the administrator. Resident council minutes documented that residents reported recent changes to food service, including removal or reduction of vegetables for burgers, PB&J sandwiches for evening snacks, and daily ice cream desserts, with no evidence the concern was addressed. Multiple resident interviews confirmed that hamburgers were served without condiments such as lettuce, tomato, and onion, and that sandwiches were very thin on meat and cheese, with bread being the main component. Residents consistently reported that if items were not on the menu, they were not provided and that the administrator had changed meals and what was allowed. Nursing and CNA staff interviews confirmed that the administrator had cut back the availability of yogurt and cottage cheese to breakfast only and that commercially prepared snacks such as chips, crackers, cream pies, pudding, and ice cream had been removed, with snacks instead being made in‑house. The cook reported there had been no dietary manager since a specific date, there was no dietitian in place until shortly before the survey, and that the administrator had taken over dietary services, reduced the amount of food ordered, and restricted what items residents could have. The newly hired dietitian stated she had just started and had not yet evaluated residents or meals. The administrator stated residents had previously agreed to a change in the alternative menu and suggested residents could use vending machines for additional snacks, but he was unable to provide information showing that alternative items available met required nutritional needs, despite a written policy requiring assessment of food preferences and dietitian evaluation of nutritional adequacy.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Harm
Penalty
Summary
The facility failed to protect residents' right to be free from physical abuse by another resident, resulting in actual harm to two residents. One resident, who was cognitively intact and dependent on staff for transfers, was involved in a physical altercation with a roommate, also cognitively intact but requiring supervision for mobility. The incident occurred in their shared room, where staff responded to a commotion and found one resident on the floor and both holding a walker. Both residents sustained injuries: one had a swollen jaw and a hematoma, while the other had a bleeding head and a fractured hand. Both were sent to the hospital for evaluation and treatment. Prior to the incident, there were indications that one resident was afraid of the other, and it was reported that the aggressive resident had previously attacked another person. The altercation was triggered when a visitor entered the room, and a misunderstanding led to one resident becoming angry and striking the other with a walker. Staff interviews confirmed that the injured resident was found on the ground, screaming for help, while the aggressor was standing over them. Law enforcement was notified, but no immediate threat was determined since the injured resident was transferred out of the facility. Medical records and interviews revealed that the injured resident was later transferred to another facility due to a blood infection affecting the spine and subsequently passed away in the hospital. The aggressive resident admitted to punching the roommate and was later involved in another episode of aggression toward staff. The facility's policy required the prevention of abuse, neglect, and exploitation, but the events leading up to and during the altercation demonstrated a failure to protect residents from physical abuse.
Failure to Discontinue Unnecessary Medications Resulting in Resident Decline
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications, resulting in a significant decline in the resident’s functional status. The resident, who was severely cognitively impaired and initially independent with mobility, was administered multiple medications including valproic acid, lacosamide, olanzapine, melatonin, and paroxetine. Despite a neurologist’s order to discontinue valproic acid and switch to lacosamide, the facility continued to administer valproic acid for an extended period. The medication administration records showed overlapping use of anticonvulsants and other psychotropic medications, with changes and discontinuations not aligning with hospital discharge instructions or family requests. The resident’s representative reported that the resident’s decline began shortly after participating in a facility event, and that the facility did not follow the neurologist’s orders to discontinue valproic acid. Hospital records indicated the resident was seen for altered mental status and somnolence, with explicit instructions to stop valproic acid and increase lacosamide if needed. However, the facility’s records showed continued administration of valproic acid even after these instructions, and the medication was not discontinued until several weeks later. Nursing notes and interviews with staff confirmed the resident’s decline in mobility and self-care, with staff unable to identify the cause at the time. Further review revealed that the resident was also receiving other medications with sedative effects, and a drug interaction check indicated a significant risk of increased sedation and drowsiness from the combination of valproic acid, olanzapine, and melatonin. Interviews with the DON and NHA confirmed a lack of awareness of the medication management issues during the period in question. The failure to appropriately manage and monitor the resident’s medication regimen led to a decline from independence to total dependence in mobility and self-care.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents on both the North and South halls, as evidenced by multiple observations, interviews, and record reviews. Residents with high acuity and total dependence on staff for activities of daily living (ADLs), such as bathing, mobility, and eating, experienced significant delays and inadequate care. For example, one resident with severe cognitive impairment and total dependence was repeatedly left waiting for meals, sometimes for extended periods, and was not consistently assisted with eating or provided with timely beverages. Bathing records showed this resident received only two baths in 22 days, despite care plans indicating a need for more frequent showers. Staff interviews confirmed that only one CNA was assigned to the dining room during meals, when ideally three were needed, resulting in delayed assistance for residents requiring help with eating. Another resident, who required extensive assistance with a bedpan and preferred morning showers, reported not receiving timely care and had to call the facility for help when call lights were not answered. Documentation and interviews revealed that this resident's requests for assistance were not promptly addressed, with call lights left on for up to an hour and staff stating they did not have time to provide care due to other duties. Resident council minutes and concern forms further corroborated ongoing issues with long call light response times, late meals, and missed showers, with residents attributing these problems to short staffing. Grievances submitted by the resident council regarding staffing concerns were not documented as being acted upon. Staff interviews consistently described an environment of inadequate staffing, high resident acuity, and insufficient supplies, leading to delays in care, incomplete ADLs, and increased staff stress. Staff reported difficulty finding assistance for two-person transfers, inability to complete showers as scheduled, and having to perform tasks outside their roles due to lack of available CNAs. Some staff admitted to transferring residents alone when two were required, and therapy staff noted that basic care was often not completed before rehabilitation sessions. Management interviews acknowledged the use of a census tool to determine staffing needs and challenges in hiring CNAs, but staff and residents continued to report unmet care needs and insufficient staffing.
Failure to Ensure Resident Dignity and Respect During Meal Service and Room Entry
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect during multiple observed incidents involving two residents. One resident, who was severely cognitively impaired, totally dependent on staff for self-care and mobility, and exhibited continuous inattention and disorganized thinking, experienced significant delays in meal service and was left unattended for extended periods. Observations showed the resident was brought to the dining room and left without food for up to 37 minutes before being served, and on another occasion, was seated facing a wall with minimal engagement or supervision. Staff interviews confirmed that only one person was assigned to the dining room during meal service, despite the need for more staff to assist residents who required help with eating, resulting in residents having to wait for assistance. Another resident, who was assessed as independent in decision-making but had a care plan for hoarding behaviors, was upset after facility staff entered their room and removed personal items while the resident was hospitalized. The NHA had directed the social worker to inform several residents, including this one, that their rooms needed to be cleaned due to fire hazard concerns. The EVS manager, following the NHA's instructions, entered the resident's room without consent and removed items belonging to the facility, such as linens and clothing protectors. The resident expressed distress over the lack of consent and the handling of their personal belongings. These incidents were corroborated by staff interviews and documentation, which revealed that the facility's actions did not align with the residents' rights to dignity, respect, and involvement in decisions about their care and personal property. The lack of adequate staffing during meal times and the unauthorized entry into a resident's room while absent were key factors leading to the deficiencies identified by surveyors.
Failure to Notify Resident Representative of Diet Change
Penalty
Summary
The facility failed to notify a resident's representative of a change in the resident's diet, as required by policy. The resident, who had a history of diabetes mellitus type 2, transient cerebral ischemic attack, Parkinson's disease, muscle weakness, and dysphagia, was assessed as moderately cognitively impaired and required assistance with daily activities. The care plan indicated the resident was at risk for nutrition-related problems and that the family had declined a recommended NPO diet, opting instead for regular chopped textures after being educated on the risks. Despite this, the resident's meal card specified a mechanical soft chopped diet for all meals, and the resident's representative was not informed of this change. Interviews with the resident and their family revealed confusion and lack of awareness regarding the diet being served. The family specifically stated they were not notified of the change from a regular to a mechanical soft diet. The NHA confirmed that the diet change was recommended following a speech language pathology evaluation and acknowledged that the family had not been notified. Review of facility policy showed that notification of a resident's representative is required when there is a significant change in the resident's status, which did not occur in this instance.
Failure to Provide Routine Bathing for Dependent Residents
Penalty
Summary
The facility failed to provide routine bathing for two residents who required assistance with activities of daily living. One resident, who was severely cognitively impaired, totally dependent on staff for self-care, and exhibited continuous inattention and disorganized thinking, was care planned to receive showers twice weekly. However, documentation showed that over a 22-day period, this resident received only two baths, and the accuracy of this documentation was confirmed by an LPN. The resident's representative also reported that the facility did not follow through with promised bathing. Another resident, assessed as independent in decision-making and not coded as rejecting care, was care planned to receive showers twice weekly in the morning. The care plan also noted occasional resistance to bathing, with interventions to reassure and reattempt care, and to document refusals. However, records indicated that the resident received only one bed bath during the review period, with no documentation of refusals, despite staff education efforts. There was a lack of further documentation to support that bathing was offered or refused as required.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement and maintain appropriate interventions to prevent the development of pressure ulcers for two residents identified as being at risk. One resident, who was severely cognitively impaired and had multiple comorbidities including dementia, diabetes, malnutrition, and mobility limitations, was documented as requiring assistance with most activities of daily living and was noted to be at risk for pressure ulcers. Despite care plans indicating the use of pressure-reducing devices and weekly skin checks, the resident developed multiple new wounds, including a stage 3 pressure ulcer. Observations and interviews revealed that interventions such as offloading devices were not consistently in use, and staff did not always remove socks during skin assessments, potentially missing early signs of skin breakdown. Another resident, also at risk for pressure ulcers and requiring moderate assistance with daily activities, was found to have developed a sacral pressure ulcer that was acquired in-house. Nursing notes indicated the presence of an unassessed wound with odor and abnormal appearance, and subsequent documentation confirmed the wound as a pressure ulcer. The care plan for this resident included weekly skin checks, but the wound was not identified in a timely manner, and the skin assessment did not reflect the presence of new wounds. Policy review showed that the facility's guidelines required evidence-based interventions and thorough skin inspections for residents at risk of pressure injuries. However, staff interviews and documentation revealed lapses in the implementation of these preventive measures, including incomplete skin assessments and inconsistent use of pressure-relieving devices. These failures contributed to the development of avoidable pressure ulcers in both residents.
Failure to Provide Timely Incontinence and Catheter Care
Penalty
Summary
The facility failed to provide timely incontinence care to two residents. One resident, who was severely cognitively impaired, totally dependent on staff for all self-care and mobility, and exhibited continuous inattention and disorganized thinking, was observed sitting in various locations for approximately six hours without receiving incontinence care. During this period, the resident was moved between the dining room, hallway, therapy room, and back to the dining room before being transferred to their room for wound care. Incontinence care was not provided until after the wound care was completed, at which point staff confirmed the resident's brief was wet. Another resident, who had an indwelling catheter and was frequently incontinent of bowel, reported not receiving timely assistance with toileting. The resident had to call the facility to request help after their call light was not answered for about an hour. Documentation and interviews confirmed that the resident's request for a bedpan was delayed, and pericare was not performed. The same staff member was involved in both reported incidents, and the concern had been previously voiced by the resident.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels and licensed nurse coverage were insufficient to comply with regulatory requirements. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Routine Bathing and Hygiene Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to provide routine bathing and assistance with activities of daily living for multiple residents who were unable to perform these tasks independently. Several residents, including those with cognitive impairments, physical disabilities, and complex medical conditions such as morbid obesity, quadriplegia, and recent trauma, experienced extended periods without bathing. Documentation and interviews revealed gaps in bathing records, with some residents going up to 23 days without a bath or shower. Residents reported dissatisfaction and discomfort due to missed bathing, and some had to escalate their requests to facility leadership to receive basic hygiene care. Staffing shortages were repeatedly cited as a reason for the lack of timely care. Resident interviews and concern forms indicated that call lights were not answered promptly, and staff communicated to residents that showers and other care could not be provided due to insufficient staffing. On at least one occasion, there were no CNAs present in the building, and no baths were given that day. Resident Council and individual grievances highlighted ongoing issues with delayed or missed care, including showers, bed changes, and assistance with personal hygiene. Facility policy required that residents be provided showers according to their requests or the facility's schedule, based on safety considerations. However, the regional clinical director confirmed that bathing was not being performed as required, and there were no additional records to support that residents received the necessary care. The failure to provide routine bathing and personal hygiene assistance was substantiated through resident and staff interviews, medical record reviews, and grievance documentation.
Failure to Document Total Nursing Staff Hours on Daily Postings
Penalty
Summary
The facility failed to ensure that the daily nurse staffing postings included the total number and actual hours worked by RNs, LPNs, and CNAs for each shift. During the review of daily staff postings over a one-month period, it was found that while staff names, positions, and individual hours worked were documented, the postings did not display the total hours worked for each category of nursing staff. This deficiency was confirmed during an interview with the administrator, who acknowledged that the required total hours for each staff category were not included in the daily postings. The facility census at the time was 69 residents. No specific resident medical history or condition was mentioned in relation to this deficiency.
Significant Medication Error Resulting in Opiate Overdose
Penalty
Summary
A resident with multiple diagnoses, including renal insufficiency, diabetes mellitus, and chronic pain syndrome, was prescribed a fentanyl transdermal patch to be applied every three days and morphine sulfate ER twice daily for pain management. On review of the medication administration record, it was found that the resident received both medications as ordered. However, on one occasion, a registered nurse applied a new fentanyl patch without removing the old one, as she did not see the previous patch and failed to document its removal. This resulted in the resident having two fentanyl patches applied simultaneously. Following this medication error, the resident experienced a change in level of consciousness and required hospitalization. Hospital discharge documentation confirmed the resident was admitted to the intensive care unit due to an accidental opiate overdose and was treated with intravenous Narcan. The facility's policy on controlled substances requires compliance with all laws and regulations regarding handling, storage, disposal, and documentation of controlled medications, but this was not followed in this instance.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with severe cognitive impairment and multiple psychiatric diagnoses was involved in an incident where another resident, who also had moderate cognitive impairment and psychiatric conditions, physically assaulted them. The aggressor was found gripping the other resident's arm and making verbal threats to kill, based on delusional beliefs that the roommate had committed murders. Staff intervened by physically separating the residents and removing the aggressor from the room. The assaulted resident sustained mild redness to the arm as a result of the incident. Prior to the incident, there were no indications in the report that the facility had identified or addressed the risk of aggressive behavior from the resident who became physically and verbally abusive. The aggressor exhibited acute changes in mental status, including delusions, agitation, and confrontational behavior, which were observed by staff and documented in progress notes. The incident was witnessed by staff who intervened after hearing raised voices and observing the physical altercation in progress. The facility's policies on resident rights and abuse prevention require protection from physical and psychosocial harm. However, the report documents that the resident's right to be free from physical abuse was not upheld, as the physical assault occurred before staff intervention. The deficiency centers on the facility's failure to prevent the abusive event, resulting in harm to a resident.
Inadequate Documentation of COVID-19 Testing During Outbreak
Penalty
Summary
The facility failed to ensure a system was in place for documenting resident and staff SARS-CoV-2 test results during a COVID-19 outbreak. The outbreak records showed that staff members tested positive on two consecutive days, and residents were tested on multiple dates, with several testing positive. Despite ongoing testing and screening of staff and residents, there was a lack of documentation for tests conducted after a certain date. Interviews with staff revealed that testing was performed as instructed, but results were not consistently documented. The former infection preventionist had resigned, and the facility's COVID-19 guidelines required testing twice a week until no new cases were reported for 14 days. However, the facility's documentation was incomplete, with no records of testing results after a specific date, despite verbal confirmations of continued testing. The NHA confirmed the outbreak was resolved, but the lack of documentation did not align with the facility's guidelines for outbreak resolution.
Failure to Communicate Changes in Resident Appointments
Penalty
Summary
The facility failed to ensure that changes in healthcare appointments were communicated to residents or their representatives, affecting two residents reviewed for post-hospitalization follow-up appointments. For one resident, an appointment with a urologist was initially scheduled and confirmed for a specific date, but was rescheduled by the facility without notifying the resident's representative. This led to a family member arriving for the original appointment only to find it had been moved. The director of social services had no documentation of the change, and the receptionist deleted the original appointment from the calendar without rescheduling it, leaving no record of the change in the resident's medical record. For another resident, a follow-up appointment was scheduled but later canceled by the provider's office, with no rescheduling or documentation of the cancellation in the resident's medical record. The receptionist confirmed the cancellation but did not update the appointment calendar. The director of social services indicated that appointment changes were managed by the DON and the receptionist, but the DON was unaware of how these changes were communicated, indicating a lack of a systematic process for managing and communicating appointment changes.
Deficiency in Tracheostomy Care Documentation and Performance
Penalty
Summary
The facility failed to provide adequate tracheostomy care for a resident with a tracheostomy, as evidenced by multiple omissions in the treatment administration record (TAR). The resident, who had a history of acute respiratory failure and other comorbidities, reported that the tracheostomy dressing had not been changed for three days, and the cannula had not been cleaned or changed for five days. The TAR showed several instances where required tracheostomy care, such as cleaning or changing the inner cannula, changing trach ties, observing skin integrity, and suctioning the tracheostomy tube, was not performed or documented. Additionally, there was no evidence of education or competency for the staff members who provided care to the resident. Interviews with staff revealed that the resident sometimes refused care, and there was a lack of documentation regarding these refusals. The Director of Nursing confirmed that the omissions in the TAR were due to either the care not being provided or not being documented. Furthermore, the facility's policy on notification of changes required documentation of care refusals, which was not adhered to. The administrator considered the involved nurses as subject matter experts but acknowledged the absence of documented competency for them.
Failure to Document Dialysis Communication
Penalty
Summary
The facility failed to ensure proper documentation of communication with the dialysis center for three residents receiving dialysis services. Resident #11, who was admitted and readmitted to the facility, was scheduled for dialysis treatments every Monday, Wednesday, and Friday. However, the Dialysis Communication Record forms for May and June 2024 showed missing documentation for several treatment dates, including 5/17, 5/31, 6/12, 6/17, 6/19, 6/21, and 6/24. Similarly, resident #35, who was admitted to the facility and received dialysis every Tuesday, Thursday, and Saturday, had missing documentation for treatments on 3/5, 3/7, 3/9, 3/21, 6/4, 6/6, and 6/8. Additionally, resident #117, who was also scheduled for dialysis every Monday, Wednesday, and Friday, lacked documentation for the 6/12 treatment. An interview with RN #1 revealed that the facility had previously used dialysis binders to track communication forms but had since discontinued their use.
Failure to Develop Complete Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop a baseline care plan addressing the immediate needs of a newly admitted resident. The resident was admitted from the hospital with diagnoses including hypertensive chronic kidney disease with stage 5 chronic kidney disease and dependence on renal dialysis. Upon review, the baseline care plan for the resident, created the day after admission, was found to have the focus area of dialysis left blank. This deficiency was confirmed during an interview with the Director of Nursing.
Failure to Update Care Plan for Resident's Smoking Needs
Penalty
Summary
The facility failed to revise the comprehensive care plan to reflect the current needs of a resident with severe cognitive impairment, as indicated by a BIMS score of 5 out of 15. The resident was known to smoke regularly, and a safe smoking assessment required the use of a smoking apron. However, the care plan did not include goals and interventions related to tobacco use. This deficiency was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the care plan had not been updated to address the resident's smoking habits. The facility's Resident Smoking Policy mandates that all safe smoking measures be documented in each resident's care plan and communicated to staff, visitors, and volunteers responsible for supervising residents while smoking. Despite this policy, the care plan for the resident in question did not reflect these requirements, leading to a deficiency in care planning for the resident's smoking needs.
Failure to Conduct Safe Smoking Assessment
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident who began smoking after admission. The resident, who was cognitively intact with a BIMS score of 15, was initially assessed as a non-smoker during the admission process. However, observations showed the resident smoking in the designated outdoor area under staff supervision. Despite the resident's new smoking habit, a safe smoking assessment was not completed, as confirmed by an interview with the DON. The facility's policy requires that all residents who smoke be assessed for safety and supervision needs, and these measures should be documented in the resident's care plan. This procedure was not followed, leading to the deficiency.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident received the pneumococcal immunization according to CDC recommendations. The resident, who is [AGE] years old, had previously received the Prevnar 23 vaccine and had signed a consent form to receive the PCV20 vaccine. However, there was no evidence in the medical record that the PCV20 vaccine was administered. An interview with the infection preventionist revealed that the resident had not been given the PCV15 or PCV20 vaccine due to an oversight. The facility's Pneumococcal Vaccine policy, dated 9/8/23, states that the type of pneumococcal vaccine offered will depend on the recipient's age and susceptibility to pneumonia, in accordance with CDC guidelines. According to the CDC's Adult Immunization Schedule, individuals 65 or older who have only received the PPSV23 vaccine should be administered either the PCV15 or PCV20 at least one year after the PPSV23 dose. This oversight led to the resident not receiving the recommended vaccination.
Failure to Update Daily Staff Posting
Penalty
Summary
The facility failed to ensure the daily staff posting was updated daily, as required. On 6/23/24, an observation at 1:34 PM revealed that the staff posting by the main entrance was dated 6/20/24, indicating it had not been updated for three days. Later that day, at 5:30 PM, the posting was changed to reflect the current date. An interview with the nursing home administrator confirmed that the update had been made recently to reflect the current day's information. Further investigation revealed that the scheduler, who was normally responsible for updating the daily staff posting, did not work on weekends and had not updated the posting on Friday, 6/21/24, because she was working on the floor. The scheduler was unaware of who was responsible for updating the posting on weekends. An interview with the Director of Nursing (DON) clarified that it was the responsibility of the manager on duty to update the daily staff posting during weekends.
Latest citations in Wyoming
A facility failed to keep residents’ personal and medical records secure and confidential. Medical record review showed hospice notes were entered directly into the EMR for three residents, and the regional clinical director stated the hospice previously used was given full access to the EMR for all residents. The Resident Rights policy stated residents have a right to secure and confidential personal and medical records.
Failure to Offer Choice of Hospice Provider: The facility did not ensure that 3 residents receiving hospice services were offered a choice of hospice provider. Medical record review showed no evidence that the residents were given provider choice, and an RCD confirmed that prior to the operator transition, hospice residents were not given a choice. The facility's Resident Rights policy states residents have the right to choose health care and providers of health care services.
Failure to Assess and Document Changes in Condition: A resident with repeated falls, hypoxia, lethargy, and later hospital transfers had multiple episodes where assessments, vital signs, or follow-up documentation were missing or delayed. Another resident with COPD and impaired gas exchange was observed in respiratory distress without oxygen and was later transferred for respiratory failure, with no transfer documentation on the progress notes. A third resident with dementia and a history of falls had incomplete post-fall assessments and was later sent to the hospital after additional falls and pain. A fourth resident with a Foley catheter had cloudy, low, and absent output, pain, and family requests for transfer; the catheter was later found to have caused traumatic injury and hematuria.
Opened medications in two medication fridges were found without required opened-on or discard dates. An Ozempic pen in one fridge and an opened Tubersol vial plus an opened Ativan oral solution in another fridge were all in use but unlabeled, and staff confirmed the missing dates. The DON stated she expected in-use multi-dose vials to have an opened-on or discard-by date, and manufacturer guidance reviewed for these medications specified discard timelines after opening.
A facility failed to ensure hospice services met professional standards for 3 sampled residents. Medical record review showed each resident was receiving hospice services, but none of the records contained a physician order for hospice referral or eval. An RCD confirmed that residents placed on hospice did not receive a physician order for eval and that the hospice used at the time had access to all resident medical records.
Infection control was not maintained during meal service and resident care. A CNA touched hair, clothing, and other surfaces while handling meal tickets, food, and drink cups without hand hygiene, including placing chips on a resident’s burger and touching cup rims. Staff also left visibly soiled linens in place for a resident with bowel incontinence, and oxygen cannulas/tubing for multiple residents were found on the floor or unlabeled, with one cannula picked up from the floor and placed on a resident.
A facility failed to ensure pneumococcal immunization status was assessed for 5 of 5 sampled residents. Medical record review showed no evidence that PCV had been assessed or offered, and the IP confirmed there was no documentation of pneumococcal vaccination status. The facility reported its immunization process tracked vaccines on admission and documented annual COVID and influenza vaccines, but the pneumococcal audit had been delayed because records could not be accessed.
Failure to timely report alleged verbal abuse: A volunteer reported that an activities staff member yelled at a resident during bingo, told the resident to stop interrupting, and also yelled at the volunteer when she intervened. The resident later described the staff member as rude and said the comment made him/her angry. Survey review found no evidence the allegation was reported, and the RCD confirmed the facility had no evidence of reporting despite policy requiring immediate reporting of abuse allegations.
Failure to Investigate Allegation of Verbal Abuse: A volunteer reported that an activities staff member yelled at a resident during bingo and then yelled at the volunteer when she intervened. Interviews with the resident and volunteer confirmed the staff member spoke rudely and loudly to the resident, and the regional clinical director confirmed there was no evidence the verbal abuse allegation was reported or investigated.
Failure to Allow Return After Hospital Transfer: A resident was transferred to the ER for altered mental status and increased confusion, but the facility did not provide a transfer/discharge notice and did not allow the resident to return after the acute hospitalization. The DON stated the decision not to permit return was financial, while the business office manager believed it was due to insufficient staffing. The facility policy stated residents transferred to acute care will be permitted to return upon discharge, and not permitting return constitutes a discharge.
Failure to Protect Confidential Medical Records
Penalty
Summary
The facility failed to ensure residents’ personal and medical records remained secure and confidential. Medical record review showed that resident #26 received hospice services beginning on 1/2/26, resident #83 received hospice services beginning on 1/21/26, and resident #84 received hospice services beginning on 2/5/26, and the hospice provided documented notes directly into the electronic medical record system. During interview on 5/6/26 at 12:44 PM, the regional clinical director stated the only hospice used prior to a change in operator was given full access to the electronic medical record for all residents. Review of the facility’s Resident Rights policy stated residents have a right to privacy and confidentiality of personal and medical records and the right to secure and confidential records.
Failure to Offer Choice of Hospice Provider
Penalty
Summary
The facility failed to ensure residents' right to choose their health care providers for 3 of 12 sampled residents reviewed for hospice services. Resident #26 began receiving hospice services on 1/2/26, resident #83 began receiving hospice services on 1/21/26, and resident #84 began receiving hospice services on 2/5/26, but the medical record review showed no evidence that any of these residents were offered a choice in hospice provider. During an interview on 5/6/26 at 12:44 PM, the regional clinical director confirmed that prior to the operator transition, residents on hospice were not given a choice for hospice provider. The facility's Resident Rights policy, last revised on 6/10/25, states that the resident has the right to choose health care and providers of health care services consistent with his or her interests, assessments, and plan of care.
Failure to Assess and Document Changes in Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for four residents who experienced changes in condition. For resident #1, the record showed multiple episodes where the resident was found after falls, had low oxygen saturations, became lethargic, or was unresponsive, yet there was no evidence of timely assessments, vital signs, or follow-up documentation at several of those events. The record also showed a late entry note for a 3/5/26 incident was added 62 days after the event. The resident was later transferred to the hospital for respiratory failure, pneumonia, acute heart failure, dry gangrene, hyponatremia, metabolic encephalopathy, pulmonary edema, critical electrolyte abnormalities, atrial fibrillation with RVR, and acute kidney injury. For resident #69, the resident had diagnoses including chronic myeloid leukemia, CAD, seizure disorder, traumatic brain injury, and COPD, and the care plan addressed impaired gas exchange. On 5/4/26, the resident was observed sitting on the edge of the bed with a respiratory rate of 30-40 breaths per minute, grey pallor, and no oxygen in place. The resident was later sent to the hospital for respiratory failure, but the progress notes for the transfer did not show documentation on 5/5/26. A later facility note stated the resident had been found with oxygen saturation of 60% on 4 lpm NC, difficulty breathing, and lethargy, and the LPN reported she had been asked to come in on her day off to document the assessment and transfer. For resident #81, who had severe cognitive impairment, dementia, COPD, atrial fibrillation, CAD, diabetes, and a history of falls, the record showed repeated falls and incomplete assessments. After a fall on 4/20/26, the assessment section was left blank. Another note dated 4/23/26 documented pain, confusion, and unsteadiness but stated there were no safety risks. After a fall on 4/25/26, staff documented vital signs and a normal assessment but did not know whether the resident hit his/her head, and there was no evidence of follow-up assessments. After a fall on 4/30/26, the resident was found on the floor with pain, and the interdisciplinary review identified impaired cognition, weakness, and self-transfers as the root cause, with a new skin tear noted. The resident's representative reported the resident was in significant pain, not at baseline, disheveled, saturated with urine, had neck swelling, and was missing a pain patch, and stated no vital signs or assessment had been done before the resident was sent to the hospital. For resident #6, who had moderate cognitive impairment, cancer, CAD, heart failure, renal disease, dementia, and an indwelling catheter, the care plan identified UTI risk related to the Foley catheter. After a recent hospitalization for sepsis related to UTI/prostate cancer, the record showed thick cloudy catheter output, complaints of pain, and periods of no catheter output. The resident's family repeatedly requested hospital transfer, and the catheter was changed after the resident had no output since the prior shift; the catheter then drained but had bloody urine. The resident later had cloudy grayish-yellow urine, was not getting up for breakfast, and was transferred to the ED. The ER report stated the Foley had caused traumatic injury and hematuria because the balloon was inflated in the prostatic urethra, and the resident also had AKI with creatinine elevated above baseline. The DON stated she expected transfer documentation to include resident condition, vital signs, notifications, and immediate or within-24-hour documentation, and confirmed that only vital signs were completed and ongoing assessment was not completed as expected.
Medication Labeling Deficiency in Two Medication Fridges
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with accepted professional principles because opened medications in two medication refrigerators did not have an opened-on or discard date. During observation in the Rock Creek medication fridge, an Ozempic 8 mg/3 ml pen was found with no opened-on or discard date. MA-C #1 confirmed the Ozempic pen had been opened and used the day before and that no date had been written on it. In the secure unit fridge, an opened Tubersol vial and an opened Ativan oral solution 2 mg/ml were observed without opened-on or discard dates. LPN #2 confirmed both medications were in use and that neither had the required dates. The DON stated she expected an opened-on or discard-by date to be written on in-use multi-dose vials. Manufacturer instructions reviewed for Ozempic, oral liquid Lorazepam, and Tubersol specified time limits for use after opening, and the facility policy required multi-use vials to include the date initially opened or accessed.
Missing Physician Orders for Hospice Referrals
Penalty
Summary
The facility failed to ensure hospice services met professional standards for 3 of 12 sampled residents. Medical record review showed that resident #7 began receiving hospice services on 3/31/26, resident #83 began receiving hospice services on 1/21/26, and resident #84 began receiving hospice services on 2/5/26, but none of the three records contained evidence of a physician order for a hospice referral or evaluation. During interview on 5/6/26 at 12:44 PM, the regional clinical director confirmed that residents placed on hospice did not receive a physician order for evaluation and that the hospice used at that time was given access to the medical record for all residents.
Infection Control Lapses During Dining, Linen Care, and Oxygen Equipment Handling
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained for resident care and meal service. During dining room observation, a CNA touched his hair, handled resident meal tickets, and repeatedly handled resident food and drink items with exposed hands without performing hand hygiene between tasks. The CNA placed a bag of chips on top of a resident’s hamburger, touched the top bun to apply jelly, handled drink cups by the rims, and continued passing trays after touching his pants, hair, and other surfaces. The infection preventionist and DON confirmed staff were expected to perform hand hygiene after touching hair, skin, or clothing and that the CNA should not have touched resident meal items without hand hygiene. The facility also failed to manage soiled linens and oxygen equipment for residents with visible contamination or tubing on the floor. One resident had linens visibly soiled with bowel movement incontinence, yet the blanket was pulled over the sheets, the soiled linen remained visible during later observations, the resident lay on top of an oxygen cannula on the soiled sheets, and housekeeping picked up the cannula from the floor and placed it on the resident. Two other residents had nasal cannulas or oxygen tubing on the floor or unlabeled, including tubing dated 4/19/26 and tubing labeled 5/3/26 that remained on the floor during repeated observations. The IP confirmed oxygen tubing should be changed and labeled weekly and as needed or when visibly soiled, that cannulas found on the floor should not be used on residents, and that soiled linens should be changed immediately.
Failure to Assess and Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure residents were immunized for pneumococcal disease for 5 of 5 sampled residents (#66, #69, #1, #33, and #4) reviewed for current vaccination status. Medical record review showed no pneumococcal conjugate vaccine had been assessed or offered for these residents. The infection preventionist confirmed there was no evidence of pneumococcal vaccination status, and also stated the facility’s immunization process assessed and tracked vaccines on admission, with annual COVID and influenza vaccines offered and documented, but that the pneumococcal vaccine audit had been delayed because records could not be accessed. CDC guidance reviewed by surveyors indicated that adults age 19 years or older with unknown or no prior PCV history should receive PCV15, PCV20, or PCV21.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse was reported timely for resident #55. A volunteer submitted a grievance stating that during bingo on 2/14/26, activities staff member #1 yelled at resident #55 after the resident called out bingo and told the resident to stop interrupting while she was talking. The volunteer reported that the staff member continued yelling for a couple of minutes, and when the volunteer intervened and told the staff member to stop yelling at the resident, the staff member yelled at the volunteer as well. The grievance also stated that two residents, including resident #55 and resident #66, reported that the activities staff member yells at them all the time and speaks to them the same way every time they play bingo. Resident #55 later stated that the issue involved the activities staff member being rude during bingo and saying, in a smart-ass way, "weren't you paying attention?" The resident said the comment made him/her angry and that [he/she] called the staff member names. The volunteer confirmed hearing the staff member speak loudly and rudely to the resident and then yell at the volunteer before storming off. Review of the state survey agency incident database showed no evidence the allegation was reported, and the regional clinical director confirmed the facility had no evidence the verbal abuse allegation was reported. The facility policy required alleged abuse to be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, immediately but no later than 2 hours when the allegation involved abuse or serious bodily injury.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse was thoroughly investigated for resident #55. A complaint/grievance form documented that a volunteer reported activities staff member #1 yelled at resident #55 during bingo after the resident called out bingo, and the volunteer stated the staff member continued yelling at the resident and then yelled at the volunteer when she intervened. The grievance also noted that two residents reported the activities staff member yelled at them all the time and spoke to them the same way during bingo. Interviews confirmed the incident involved rude and loud comments by the activities staff member toward resident #55 during bingo, including telling the resident to stop interrupting and making a smart-ass remark. Resident #55 stated the interaction upset him/her and that the staff member was later terminated. A volunteer corroborated hearing the staff member speak loudly and rudely to the resident and then yell at the volunteer. Review of the state survey agency incident database showed no evidence the allegation was reported, and the regional clinical director confirmed the facility had no evidence the verbal abuse allegation was investigated.
Failure to Allow Return After Hospital Transfer
Penalty
Summary
The facility failed to ensure resident #82 was allowed to return after an acute hospitalization. A progress note dated 3/11/26 at 8:33 PM documented that the resident was transferred to the hospital emergency room for altered mental status and increased confusion. The medical record showed no evidence that a transfer/discharge notice was provided at the time of transfer. A discharge MDS assessment showed the resident’s return to the facility was anticipated and that the discharge was unplanned, with a discharge status of Short-Term General Hospital (acute hospital, IPPS). Interviews confirmed the resident did not return to the facility after the hospital transfer. The DON stated on 5/7/26 at 9:45 AM that the decision not to allow the resident to return was financial, and also confirmed that no discharge notice was provided after transfer and that the facility did not assist in finding alternate placement. The business office manager stated on 5/7/26 at 10:54 AM that the resident was not allowed to return following the hospital transfer, although he believed the reason was insufficient staffing. The facility policy stated that residents transferred to acute care will be permitted to return upon discharge and that not permitting a resident to return following hospitalization constitutes a discharge.
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