Wind River Rehabilitation And Wellness
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverton, Wyoming.
- Location
- 1002 Forest Dr, Riverton, Wyoming 82501
- CMS Provider Number
- 535031
- Inspections on file
- 23
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Wind River Rehabilitation And Wellness during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including osteoporosis and morbid obesity, had physician orders for weekly alendronate and tirzepatide that were repeatedly not administered because the medications were documented as "on order from pharmacy" over several months. MAR review showed numerous missed doses of alendronate and a gap in tirzepatide orders and administration, while a physician note indicated the resident ran out of tirzepatide and that staff had not picked up alendronate from the pharmacy or called for refills. The physician reported ongoing problems with medications not being available, lack of notification from the facility, and failure by staff to pick up ordered medications despite being informed of pharmacy pickup timeframes and alternative local pharmacy options.
A resident with chronic sacral and lower extremity wounds and a newly placed Foley catheter received perineal, catheter, and sacral wound care from the DON and an LPN without the use of required enhanced barrier precautions. During the observed care, staff performed hand hygiene and used gloves, changing them between care steps, but did not don gowns or any additional PPE. The DON later acknowledged that residents with wounds and indwelling devices should be on enhanced barrier precautions, and facility policy specified that gowns and gloves are required for high-contact care of residents with chronic wounds or indwelling medical devices.
Surveyors found persistent strong urine odors in a care unit, including hallways, a dining area, and a resident's room, despite staff assistance and administrative awareness of the issue. The facility did not ensure a clean, odor-free environment for residents.
Staff in the kitchen used hand sanitizer instead of washing hands with soap and water between food preparation tasks, including after handling raw meat and before preparing salads. The dietary manager was unaware that this practice was not compliant, and the facility's policy stated that antimicrobial gels cannot replace proper handwashing in foodservice. The FDA Food Code requires handwashing with soap and water before using hand antiseptics.
Multiple infection prevention and control lapses were identified, including a resident's Foley catheter bag left uncovered on the floor, improper storage of oxygen tubing for two residents, an LPN administering medications without changing gloves or hand hygiene, and a staff member transporting unbagged soiled linen without gloves. Additionally, a resident with pneumonia and a UTI was exposed to staff moving between ill residents without proper infection control practices.
A resident with paraplegia and morbid obesity, who was cognitively intact and dependent on staff for mobility, was not assisted out of bed or provided with a suitable wheelchair as requested. The resident expressed a desire to get up and bathe in the whirlpool, but staff were unaware of these preferences and no wheelchair was available, resulting in the resident remaining bedbound since admission.
Two residents did not receive activities tailored to their preferences and needs, with one bedbound resident unable to participate due to lack of a wheelchair and staff assistance, and another resident with anxiety and depression reporting no interest in available activities and minimal participation documented. The activities director confirmed gaps in one-to-one activity provision and a lack of nighttime options, despite facility policy requiring individualized activities.
An LPN administered medications to a resident by opening a duloxetine delayed release capsule and crushing a potassium chloride extended release tablet, both of which should have been swallowed whole according to manufacturer guidelines and facility policy. This resulted in a medication error rate of 7.69%, exceeding the acceptable 5% threshold.
A resident with severe cognitive impairment and a history of exit-seeking behaviors was able to leave the facility without staff knowledge on two occasions, despite being identified as a high elopement risk. The resident was found outside the facility by staff and law enforcement after each incident. The facility did not provide adequate supervision or ensure the environment was free from accident hazards, resulting in a deficiency.
A resident with severe cognitive impairment physically abused another resident, resulting in bruising and a scrape. The facility updated the care plan and placed the perpetrator on 1:1 supervision. However, the facility did not provide documentation of post-incident steps, such as staff education or monitoring, with the last abuse education occurring before the incident.
The facility failed to monitor two residents with edema according to physician orders. One resident with heart failure and other conditions did not have daily weights documented on multiple dates, as confirmed by the administrator and physician. Another resident, concerned about swollen legs, had an order for daily weights for five days, but only one weight was documented. The administrator and physician confirmed the weights were not performed as ordered.
The facility failed to follow physician's orders and professional standards for two residents with pressure ulcers. One resident's condition worsened due to inadequate repositioning and missing documentation of wound care. Another resident experienced a delay in wound vac placement, with verbal orders not entered into the electronic health record. The facility lacked a wound care policy, leading to deficiencies in care.
A facility failed to implement physician-ordered medication changes for a resident with multiple diagnoses, including CAD and diabetes. Despite receiving the medications from the pharmacy, they were not entered into the system, and the resident did not receive them. The DON attributed the oversight to a transition period, and the administrator noted a nurse's misunderstanding of the medications as refills.
The facility failed to promptly identify and intervene for acute changes in condition for two residents. One resident experienced severe shoulder pain after a fall and did not receive timely medical evaluation or pain management. Another resident exhibited signs of increased back pain after a fall and was not sent for x-rays until several days later, revealing compression fractures. Both residents experienced actual harm due to the facility's inaction.
A resident with chronic pain conditions experienced severe pain following a fall, but the facility failed to administer the ordered PRN Oxycodone and did not document the pain level and location. The resident's pain was inadequately managed with only topical gel and routine Tylenol, leading to actual harm and a delayed medical evaluation.
The facility failed to ensure a safe and clean environment, with issues such as broken floor tiles, unsanitizable handrails, a dirty mechanical lift, and damaged heater vent covers. Persistent urine smells and built-up dirt and debris were also noted. Interviews revealed awareness of these issues and ongoing efforts to address them.
The facility was found deficient in food safety practices, including improper use of hair restraints by the CDM, inadequate hand hygiene and glove use by kitchen staff, and failure to manage expired food items. The CDM did not wear a beard restraint, and a cook used the same gloves for different tasks without washing hands, violating the 2022 Food Code. Expired tortillas were also found in storage, with the CDM unaware of their status.
The facility failed to follow the menu for residents on a consistent carbohydrate diet (CCHO) during a lunch meal. Multiple residents were served cranberry sauce over pork, whole or half potatoes, beets, and rolls, contrary to the specified CCHO menu. The certified dietary manager confirmed the discrepancies.
A resident with severely impaired cognition had their hair cut by facility staff without family consent, despite prior arrangements for a specific hairdresser. The family filed a grievance, expressing dissatisfaction with the unauthorized haircut, which was intended to make the resident presentable for Thanksgiving.
The facility failed to follow its grievance procedure for a resident who reported missing items upon discharge. The resident's representative reported the missing items to the social services director, but a grievance form was not completed, and the grievance was not logged. The facility's grievance policy requires that grievances be routed to the appropriate personnel and logged, with a written decision provided to the person with the grievance.
A facility failed to follow proper infection prevention techniques during wound care for a resident. An RN did not change gloves or perform hand hygiene between handling soiled and clean dressings, and used contaminated scissors without cleaning them. The infection preventionist confirmed these actions did not meet expected standards.
Two residents with pressure ulcers did not receive necessary wound care as per physician orders in a timely manner. One resident, at risk due to renal insufficiency, developed a blister on the heel, and another with cellulitis had a stage 2 ulcer. Both residents lacked documented care on specific days, and the DON could not provide additional documentation, indicating a deficiency in wound care management.
The facility failed to provide therapeutic diets as ordered, with two residents receiving improperly thickened liquids. A CNA used an unlabeled thickener for a resident with a specific order, resulting in coughing, while another CNA used thickener for a resident without an order. Staff interviews revealed confusion over thickener use, with the DON stating that dietary staff should handle thickening.
Failure to Ensure Availability and Administration of Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure ordered medications were available and administered as prescribed for a cognitively intact resident with paraplegia, cervicalgia, spina bifida, morbid obesity, and osteoporosis. The resident had physician orders for weekly oral alendronate sodium for osteoporosis and weekly subcutaneous tirzepatide (Zepbound) for morbid obesity. Review of the MARs over several months showed alendronate was repeatedly not administered and documented as “on order from pharmacy” on multiple scheduled administration dates in August, September, October, November, December, and January. In addition, there was a gap in tirzepatide orders and administration, with no evidence of an active order or administration for a period in December despite a prior start date and a later increased-dose order. A physician consult documented that the resident had run out of tirzepatide and that no one had called for a refill, and also that the SNF had not picked up the alendronate, despite the physician’s review with nursing and the DON that these medications needed to be picked up and not allowed to run out. The physician further reported ongoing issues with medications not being available, the facility not notifying him, and the facility not picking up medications from the pharmacy, even though he had informed them that medications would be available for pickup within 24–48 hours after ordering and that they could obtain them from a local pharmacy if needed. These actions and inactions by facility staff led to multiple missed doses of ordered medications for the resident.
Failure to Use Enhanced Barrier Precautions During Wound and Catheter Care
Penalty
Summary
The facility failed to implement its infection prevention and control program by not using enhanced barrier precautions during wound care for one resident. The resident had an open sacral wound documented by telephone order on 1/11/26 and an open wound on the right lower extremity documented in a progress note on 1/18/26. A hospital discharge summary dated 1/23/26 further showed the resident had been treated for a right lower extremity wound and cellulitis, had an open sacral wound, and had a newly placed Foley catheter. These conditions met the facility’s criteria for enhanced barrier precautions, including the presence of chronic wounds and an indwelling medical device. During an observation of wound care on 2/5/26 at 9:22 AM, the DON and an LPN entered the resident’s room, performed hand hygiene, and donned gloves. The DON provided perineal and Foley catheter care due to incontinence of loose stool, then changed gloves and performed sacral wound care, including removal of the dressing, cleansing of the wound, and application of a new dressing, with hand hygiene and glove changes between steps. However, no gown or other additional personal protective equipment was used at any time during the care. In a subsequent interview, the DON stated that enhanced barrier precautions, including the use of gowns and gloves during high-contact care activities, should be used for residents with wounds, catheters, and similar devices, and confirmed that this resident should have been on enhanced barrier precautions. Review of the facility’s Transmission-Based Precautions policy, last updated March 2025, showed that enhanced barrier precautions are required for residents with chronic wounds or indwelling medical devices.
Failure to Maintain Odor-Free and Clean Environment
Penalty
Summary
Surveyors observed persistent strong urine odors in one of four resident care units over several days. On multiple occasions, strong urine odors were noted in the hallway near the assisted dining room, near specific resident rooms, and within the assisted dining area itself. In one instance, a resident's room continued to have a strong urine odor even after the resident had left and staff had provided assistance. During an interview, the facility administrator acknowledged awareness of the ongoing odor issue and stated that while some improvement had occurred, further action was still needed. The facility had also been discussing alternative storage for soiled linen on the affected hall. These findings indicate that the facility failed to maintain a clean, odor-free environment as required, impacting the comfort and homelike atmosphere for residents.
Improper Hand Hygiene Practices in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen as required by professional standards and the 2022 FDA Food Code. During observation, a cook was seen using hand sanitizer instead of washing hands with soap and water between food preparation tasks, including after handling raw meat and before preparing salads. The cook sanitized her hands with gel sanitizer and donned gloves between tasks, only washing her hands with soap and water after several steps. Interviews with the cook and the dietary manager confirmed that staff routinely used hand sanitizer between glove changes, and the dietary manager was unaware that this practice was not compliant with food safety standards. Review of the facility's own handwashing policy indicated that antimicrobial gels cannot be used in place of proper handwashing in a foodservice setting. The FDA Food Code specifies that hand antiseptics may only be used on hands that have already been properly washed, and if not meeting certain criteria, must be followed by thorough rinsing with clean water before food contact or glove use.
Infection Control Lapses in Catheter, Respiratory, Medication, and Linen Handling
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several areas, as observed through staff interviews, medical record reviews, and policy reviews. For one resident with a Foley catheter, the catheter bag was found on the floor and uncovered while the resident was in bed, contrary to facility policy requiring the bag to be secured below the bladder and covered. Another resident diagnosed with pneumonia and later a UTI was reportedly exposed to staff moving between ill residents without appropriate infection control measures, as described by the resident's representative and confirmed by the DON that there were multiple cases of respiratory illness in the facility during that period. Additional deficiencies were observed in respiratory care, where two residents' oxygen tubing and nasal cannulas were improperly stored, left balled up or touching equipment instead of being placed in designated storage bags as per policy. During medication administration, an LPN handled medications with gloved hands that had touched other surfaces, without changing gloves or performing hand hygiene, before administering the medications. Furthermore, a staff member was seen transporting unbagged soiled linen in her ungloved hand across the hall, which was inconsistent with facility policy requiring soiled linen to be bagged and handled with gloves when removed from resident rooms.
Failure to Accommodate Resident's Mobility and Bathing Preferences
Penalty
Summary
A deficiency was identified when a resident with paraplegia, spina bifida, and morbid obesity, who was cognitively intact and dependent on staff for mobility, was not accommodated according to their expressed needs and preferences. The resident reported being bedbound since admission and expressed a desire to get out of bed and use a wheelchair, as well as to bathe in the whirlpool. Observation confirmed the absence of a wheelchair in or near the resident's room, and the resident had not been assisted out of bed since admission. Interviews with facility staff revealed a lack of communication regarding the resident's preferences. The social services director was unaware of the resident's desire to get up or their bathing preferences. The administrator and DON indicated that therapy was attempting to contact the resident's family to obtain the resident's personal wheelchair, as the facility's available shower chair was unsuitable due to the resident's poor trunk control. The regional clinical director confirmed that therapy was assessing the safety of using a facility wheelchair and that the resident was to discuss the matter with their family. Despite these discussions, the resident remained bedbound and their needs and preferences were not accommodated.
Failure to Provide Individualized Activities Based on Resident Preferences
Penalty
Summary
The facility failed to provide individualized activities based on resident preferences for two of three sampled residents. One resident, who was cognitively intact and bedbound due to paraplegia, spina bifida, and morbid obesity, expressed a strong desire for reading materials, music, and outdoor access, but was unable to participate in activities due to the lack of a wheelchair and insufficient staff to assist with mobility. Documentation showed this resident did not participate in any group activities over a 73-day period and only received one-to-one activities on five occasions, with all other activities marked as independent. The resident reported feeling isolated and noted a lack of staff engagement in their room. Another cognitively intact resident with anxiety and depression also reported that none of the facility's activities were of interest. This resident's records indicated participation in only one group activity and two one-to-one activities over a 94-day period, with the remainder marked as independent. The activities director confirmed the lack of documented one-to-one activities and acknowledged that there were no activities available at night, which was when this resident was most active. Facility policy required the provision of individualized and in-room activities, but these were not consistently provided according to the residents' needs and preferences.
Medication Error Rate Exceeds Threshold Due to Improper Administration
Penalty
Summary
During a medication administration observation, an LPN prepared and administered seven medications to a resident, including potassium chloride extended release and duloxetine hydrochloride delayed release. The LPN opened the duloxetine capsule and placed its contents in a medication cup, then crushed the potassium chloride tablet along with other medications before mixing them with applesauce and administering them to the resident. Review of the resident's physician orders indicated that medications could be crushed unless contraindicated, but specifically ordered duloxetine as a delayed release capsule and potassium chloride as an extended release tablet, both of which should not be altered. Manufacturer guidelines for both duloxetine delayed release and potassium chloride extended release specify that these medications should be swallowed whole and not crushed, chewed, or opened. The facility's own policy also states that long-acting, extended release, or enteric coated dosage forms should generally not be crushed, and alternatives should be sought. The medication error rate during this observation was calculated at 7.69%, exceeding the acceptable threshold of 5%.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a BIMS score of 2 out of 15 and a diagnosis of moderate dementia with behavioral disturbances, was admitted to the facility. The initial elopement risk evaluation did not identify the resident as an elopement risk, but subsequent assessments and care plan updates noted a history of attempts to leave the facility unattended, impaired safety awareness, and verbalized intent to go home. Despite these risk factors, the resident was able to leave the facility without staff knowledge on two separate occasions. On one occasion, the resident was noticed missing after having spent most of the day outside. Staff initiated a search, contacted local law enforcement, and found the resident returning to the facility after having walked to a store. On another occasion, the resident was again found missing, and staff discovered the resident's wanderguard device on the floor of the resident's room. After a search and notification of police, the resident was located walking on a main street and brought back to the facility. The resident refused a full body skin assessment upon return. Observations during the survey confirmed that the resident continued to spend time outside, often accompanied by 1:1 staff supervision. Interviews with the resident and the resident's representative confirmed the resident's preference for being outdoors and the facility's ongoing efforts to monitor and supervise the resident. The facility's failure to prevent the resident from leaving the premises without staff knowledge, despite known risk factors and previous incidents, constituted a deficiency in providing adequate supervision and ensuring the environment was free from accident hazards.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a deficiency. The incident involved a resident with severe cognitive impairment who exhibited physical behavioral symptoms. This resident, while ambulating to their room, encountered another resident and pinched them on the arm. The care plan for the perpetrating resident was updated to reflect the altercation, and they were placed on a 1:1 supervision following the incident. The victim, also with severe cognitive impairment, sustained bruising and a slight scrape on the arm, with documentation noting scratch marks with dried blood. The facility's investigation revealed that the incident was witnessed by staff, and the perpetrating resident was placed on 1:1 supervision immediately. However, the facility failed to provide documentation of steps taken after the incident, such as staff education, audits, monitoring, or quality assurance measures. The last recorded staff education on abuse was conducted prior to the incident, and no further documentation was provided to show any additional measures taken to prevent future occurrences.
Failure to Monitor Residents with Edema as Ordered
Penalty
Summary
The facility failed to ensure proper monitoring in accordance with physician's orders for two residents with edema. Resident #16, who had diagnoses including heart failure, renal insufficiency, pulmonary hypertension, and localized edema, was ordered daily weights starting on 10/29/24. However, the medical record showed that daily weights were not documented on several dates, and the administrator confirmed that the weights were not done as per the physician's orders. Physician #1 also confirmed that the daily weights were not conducted as ordered. Similarly, Resident #14, who expressed concern about swollen legs, had an order for daily weights for five days starting on 11/4/24, with instructions to notify the physician if there was a 3-pound gain in 24 hours. The treatment administration record and vital signs log revealed only one weight documented on 11/5/24. The administrator confirmed the order for daily weights was either not done or not documented, and physician #1 confirmed the daily weights were not performed as ordered.
Deficient Wound Care Documentation and Practice
Penalty
Summary
The facility failed to provide care in accordance with physician's orders and professional standards of practice for two residents with pressure ulcers. One resident, who was bedbound due to myelopathy and had chronic recurring pressure ulcers, experienced a worsening of their condition from a stage 3 to a stage 4 pressure ulcer on the sacrum. Despite being on an air mattress and having good nutrition and diabetes control, the resident frequently refused repositioning, which was necessary for pressure relief. The facility's documentation was lacking, with multiple instances where wound care was not documented as completed according to physician orders. Additionally, the facility did not have a wound care policy, and the administrator acknowledged missing documentation for wound care on several occasions. Another resident, admitted with cellulitis of the groin and a multi-drug resistant organism, was supposed to have a wound vac placed upon admission, but it was delayed by a day. The wound care nurse performed a dressing change with verbal orders from the provider but failed to enter them into the electronic health record. There were no documented orders for wound care until the wound vac was received, and the facility's policy required immediate input of physician's orders into the electronic health record. The physician confirmed that an order for wound care was given prior to the wound vac's arrival due to the wound's condition.
Failure to Implement Physician-Ordered Medication Changes
Penalty
Summary
The facility failed to provide medications to meet the needs of a resident diagnosed with abscess liver, coronary artery disease (CAD), hypertension, and diabetes mellitus. On 9/26/24, a physician documented medication changes for the resident, including starting aspirin for CAD, Ursodiol for a pericholecystic abscess, stopping Furosemide to monitor volume status, and switching diabetes medication from Glipizide to Empagliflozin. However, a review of the medication administration record (MAR) revealed that these changes were never implemented before the resident's discharge. The Director of Nursing (DON) acknowledged the oversight, attributing it to a transition period as she was new to the role. The facility received the medications from the pharmacy, but they were not entered into the system, and the resident did not receive them. The administrator explained that the nurse who signed for the medications mistakenly thought they were refills, not new prescriptions.
Failure to Promptly Identify and Intervene for Acute Changes in Condition
Penalty
Summary
The facility failed to promptly identify and intervene for an acute change in condition for two residents who experienced a change in condition. Resident #29, who had diagnoses including polyosteoarthritis and non-Alzheimer's dementia, fell and complained of severe shoulder pain. Despite multiple observations and complaints of pain, the resident did not receive a thorough assessment or timely medical intervention. The resident's pain was not adequately managed, and there was a delay in scheduling an appointment with the primary care physician, leading to the resident being sent to the ER for imaging two days after the fall, where old injuries aggravated by the fall were identified. Resident #31, who had severe cognitive impairment and non-Alzheimer's dementia, fell and exhibited signs of increased back pain. Despite multiple nursing notes indicating the resident's pain and guarding behavior, the resident was not sent for x-rays until several days after the fall. The x-rays revealed age-indeterminate compression fractures and degenerative arthroplasty. The delay in sending the resident for imaging was attributed to a lack of communication among the nursing staff and the DON. Both residents experienced actual harm due to the facility's failure to promptly assess and intervene for their acute changes in condition. The lack of timely medical evaluation and pain management resulted in prolonged discomfort and delayed diagnosis of injuries for both residents.
Inadequate Pain Management Following Resident Fall
Penalty
Summary
The facility failed to adequately treat pain for a resident who experienced a change in condition, including limited movement and severe pain following a fall. The resident, who had diagnoses including polyosteoarthritis, non-Alzheimer's dementia, and other chronic pain, was found on the floor with a new laceration and shoulder pain. Despite the resident's complaints of severe pain, rated as high as 10, the staff did not administer the PRN Oxycodone as ordered and instead only applied topical Diclofenac Sodium Gel and gave routine Tylenol. The resident's pain level and location were not documented on the MAR for the day of the fall, and the resident was not seen by a doctor until the following day when imaging was ordered due to increased pain and decreased function of the arm. The resident was later found to have aggravated old injuries but no acute injury and was sent back to the facility with a sling and pain medication from the hospital ER. The facility's policy required pain levels to be evaluated every shift and treated accordingly, but this was not followed in the resident's case, leading to inadequate pain management and actual harm to the resident.
Facility Fails to Ensure Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a safe and clean environment for residents, staff, and the public. Observations revealed multiple issues, including broken floor tiles with built-up dirt and debris, discolored and unsanitizable handrails, and a mechanical lift with dirt and debris on the standing platform. Additionally, a heater vent cover in a resident's room had visible rust and sharp edges, and the carpet in a common area was worn down and discolored. The tan and black couch in the same area had visible discoloration and tears in the cushions. A persistent urine smell was noted in the hallway near certain rooms, and transitions between hallways and rooms had built-up dirt and debris. These observations were confirmed by the maintenance director and housekeeping manager, who acknowledged the cleanliness and safety concerns, including damaged heater vent covers and chipped handrails with sharp edges. Interviews with the administrator, maintenance director, and housekeeping supervisor revealed awareness of the cleanliness issues and ongoing efforts to address them. The administrator mentioned plans to end the contract with the current housekeeping agency and upgrade certain areas, including the carpet in the television area. The maintenance director and housekeeping supervisor confirmed the difficulty in cleaning certain areas due to alarmed doors and plumbing leaks. They also acknowledged the time-consuming process of sanding and sealing handrails and the safety risks posed by damaged heater vent covers and handrails.
Deficiencies in Food Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food storage and preparation, as evidenced by several observations. The certified dietary manager (CDM) was observed on multiple occasions not wearing a beard restraint while in the kitchen and during tray line service, despite the 2022 Food Code requiring such restraints to prevent hair from contacting food and clean equipment. The CDM admitted to being aware of beard restraints but had never worn one. Additionally, during tray line service, a cook was observed using the same pair of gloves to touch both microwave buttons and food items, such as grilled cheese sandwiches and baked potatoes, without changing gloves or performing hand hygiene in between tasks. This was contrary to the 2022 Food Code, which mandates handwashing and glove changes between different tasks to prevent cross-contamination. The facility also failed to manage expired food items properly. During an inspection of the dry storage room, two packages of flour tortillas were found to be expired. Despite this, one of the expired packages remained on the shelf during a subsequent observation. The CDM was unaware of the expired status of these tortillas and initially claimed that all items in dry storage were usable. Upon further inspection, it was revealed that the entire box of flour tortillas received by the facility was expired, indicating a lapse in monitoring and managing food inventory effectively.
Failure to Follow CCHO Diet Menu
Penalty
Summary
The facility failed to ensure the menu was followed for residents on a consistent carbohydrate diet (CCHO) during the lunch meal on 3/13/24. The menu for the CCHO diet specified baked pork loin without cranberry sauce, half a baked potato, beets, and no roll. However, observations during tray line service revealed that multiple residents on the CCHO diet were served cranberry sauce over the pork, whole or half potatoes, beets, and rolls. Specifically, residents with different texture modifications such as puree and soft and bite-sized textures also received cranberry sauce and rolls, contrary to the menu requirements. The certified dietary manager confirmed that the CCHO diet should not have included cranberry sauce or rolls and should have included only half a potato.
Failure to Respect Resident's Grooming Preferences
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and care in a manner that promoted quality of life. The resident, who had severely impaired cognition and required extensive assistance with dressing, toileting, and personal hygiene, had a haircut performed by the facility staff without the family's consent. The resident's daughter had previously arranged for a specific hairdresser to cut the resident's hair and had instructed the facility to notify her if the resident needed a haircut. However, the staff, who were relatively new to the unit, were unaware of this arrangement and proceeded to cut the resident's hair to make them presentable for Thanksgiving. This action led to dissatisfaction and a grievance filed by the family, as the resident's head was buzzed against the family's wishes. The social services director confirmed that the family had not requested the haircut and that the facility did not notify the family before cutting the resident's hair. The director also mentioned that the staff was educated afterward. The resident's daughter expressed her frustration, stating that the facility had cut the resident's hair before without authorization and that the resident did not look good after the haircut. The facility's baseline plan of care indicated that the daughter should be contacted for any changes in care or treatment, including grooming and personal hygiene assistance, which was not followed in this instance.
Failure to Follow Grievance Procedure for Missing Items
Penalty
Summary
The facility failed to follow its grievance procedure for a resident who reported missing items upon discharge. The resident's representative reported the missing items, which included swim shoes, two white shirts, a pair of pajamas, and a glasses case, to the social services director at the time of discharge. Although one shirt was found and returned, the other items remained missing, and the facility did not contact the resident's representative for resolution. The grievance log for February and March 2024 showed no evidence of a grievance related to the missing items. The social services director confirmed that he was notified about the missing items after the resident's discharge but did not complete a grievance form because the facility was still looking for the items and the resident's representative was aware. The facility's grievance policy requires that when an immediate resolution is not possible, the grievance should be routed to the Grievance Official and/or Social Services/designee within 24 hours, and a grievance form should be filled out. The policy also states that the person with the grievance has a right to a written decision regarding their grievance, and the grievance forms should be logged on the grievance log.
Infection Control Lapses During Wound Care
Penalty
Summary
The facility failed to ensure proper infection prevention techniques during wound care for a resident. During an observation, an RN was seen cleaning a surgical wound on the resident's abdomen without removing her gloves or performing hand hygiene before handling clean dressings. The RN also used scissors from her pocket to cut tape and applied it to the dressing without cleaning the scissors. Additionally, the RN touched the floor with clean gloves while changing the resident's heel dressing, then proceeded to handle clean dressings and scissors without changing gloves or performing hand hygiene. The contaminated scissors were then placed back into the RN's pocket without being cleaned. An interview with the wound nurse/infection preventionist confirmed that the RN's actions did not meet the expected infection control standards. The infection preventionist stated that items used in a resident's room should be considered contaminated and cleaned before leaving the room. She also confirmed that gloves should be changed after cleaning a wound and before touching clean dressings to prevent contamination. A review of professional guidelines supported these expectations, emphasizing the importance of hand hygiene and proper glove use during wound care.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment to promote healing for two residents with pressure ulcers. Resident #50, who was at risk for pressure ulcers due to renal insufficiency, developed a serosanguinous filled blister on the left heel shortly after admission. Despite physician orders for daily dressing changes, the resident reported not receiving treatment for a couple of days, and the medical record lacked documentation of wound care on two specific days. The Director of Nursing (DON) confirmed that wound documentation should be in the medical record but did not provide additional evidence of care. Similarly, resident #105, diagnosed with weakness and cellulitis, had a stage 2 pressure ulcer on the right heel. Physician orders required daily dressing changes, but the medical record showed no evidence of treatment on the same two days as the other resident. The DON again stated that wound documentation should be present but failed to provide further documentation. These lapses in care and documentation indicate a deficiency in the facility's wound care management.
Failure to Provide Therapeutic Diets as Ordered
Penalty
Summary
The facility failed to ensure therapeutic diets were provided in accordance with physician's orders during meal observations. Specifically, thickened liquids were not appropriately provided for two residents. During an observation, a CNA used an unlabeled and undated container of white powder, referred to as thickener, to prepare a drink for a resident with an active physician's order for mildly thick liquid consistency. The resident coughed several times after drinking and did not consume more of the beverage. Another CNA was observed using a similar unlabeled container of thickener for a different resident, who did not have an active order for thickened liquids. The CNA admitted to being unfamiliar with the powdered thickener and typically used a liquid thickener with a pump for consistency. Interviews with staff revealed that the kitchen usually measured out the powdered thickener, and the facility typically used liquid thickener with instructions for use. However, the containers on the cart lacked scoops for measurement. The facility dietitian indicated that questions about thickening liquids should be directed to the DON and administrator, and that pre-thickened liquids were available. The DON stated that floor staff should not be responsible for thickening liquids, as this task should be performed by dietary staff only.
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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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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