Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Worland Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with chronic kidney disease, HTN, and atherosclerotic heart disease was found with an unlabeled cup containing an unmarked white pill after a traveling nurse had previously offered what the resident described as a sodium chloride “salt pill” instead of the prescribed sodium bicarbonate for acute kidney failure. The resident refused the pill, but the nurse reportedly stated it made no difference and left the medication behind. Record review showed no order for sodium chloride and no self-administration assessment. The DON could not verify what the pill was, when it was given, or if it was documented on the MAR, and the regional clinical nursing director acknowledged there was no facility policy on medication administration.
Staff failed to follow infection prevention and control practices for handling contaminated laundry on one unit. A CNA was observed leaving a room carrying unbagged, soiled bed linens down the hallway and placing them directly into a dirty linen bin instead of bagging them inside the room. In an interview, the DON confirmed that soiled linens are required to be bagged before leaving the room, and the facility’s “Soiled Laundry and Bedding” policy states that contaminated laundry must be placed and transported in bags or containers according to established handling and disposal procedures.
A resident with severe cognitive impairment and a history of dementia, anxiety, and depression had increasing right leg pain, swelling, discoloration, and deformity over a period of weeks, repeatedly reported by CNAs to nursing staff and treated with pain medication. On one evening, an LPN and the DON noted new or worsening edema, bruising, visible deformity, decreased ROM, and non–weight-bearing status of the right lower extremity, and the provider ordered transfer to the ER, where a right femur fracture was identified. Although the injury was recognized as an injury of unknown source and administrative staff were notified, the facility’s incident report to the State Agency was not submitted until many hours later, exceeding the policy requirement to report such allegations within 2 hours when they involve abuse or result in serious bodily injury.
A resident with CHF, UTI, mild cognitive impairment, and other conditions was admitted for skilled rehab and nursing care with a physician-certified 30‑day stay and a recommendation for post‑SNF care at an ALF. A care conference set an approximate discharge in about 10 days, and an LPN documented that discharge orders were received and carried out, with stable vital signs, discharge instructions, and medications provided before the resident left via personal transport. Subsequent interviews with the NP, SSD, NHA, and regional clinical director revealed that no provider had actually issued or signed discharge orders, there was no discharge visit, no scheduled follow‑up physician visit, and no written PT/OT orders, and that staff only realized after the resident left that the physician had not been contacted, resulting in the resident being discharged without proper provider authorization.
The facility failed to prevent accident hazards and provide adequate supervision related to hot beverage service. A resident with moderate cognitive impairment, stroke, hemiplegia, contractures, and dysphagia, who was care-planned to receive hot liquids only in a Kennedy cup and at non-scalding temperatures, was instead given hot coffee in a Styrofoam cup without a lid and left unsupervised, resulting in burns to the thighs requiring ED treatment. Surveyors also observed multiple residents independently dispensing very hot coffee or water directly from a machine into open cups, then ambulating with walkers while carrying these beverages, sometimes spilling them. Staff interviews confirmed that machine water was not supposed to be served directly to residents, that dining room staffing was often below the intended level, and that there were no clear interventions to prevent residents from independently accessing the hot beverage machine, leading to an immediate jeopardy finding.
Two cognitively impaired roommates, one with severely impaired memory and verbal behavioral symptoms and the other with moderate cognitive impairment, dementia, and anxiety, became involved in a physical altercation after a CNA briefly left their shared room. Staff heard loud noises and found one resident with a raised fist and the other holding a Bible raised toward the first, with both admitting they had been fighting and one stating the other was in the way. The injured resident was found to have blood, scratches, and two small abrasions on the left cheek, while the other had no injuries, demonstrating a failure to protect a resident from physical abuse by another resident.
A resident reported $200 missing from their bedside table, but the facility failed to report the allegation to the state survey agency as required by their policy. The resident, who was cognitively intact, informed the social services director, but the investigation was not reported, violating the facility's reporting policy.
A resident with dementia and behavioral symptoms was not engaged in activities as per their care plan, despite the facility's policy to provide resident-centered activities. Observations showed the resident pacing and not being assisted to participate in scheduled activities. The facility was short-staffed, affecting the implementation of the activities program.
A facility failed to follow the dietary orders for a resident with diabetes, serving a full cinnamon roll with glaze instead of the prescribed half portion without glaze. The resident, who was cognitively intact, confirmed the deviation from the diabetic diet plan. Interviews with the dietitian and dietary manager highlighted that the facility's protocol requires adherence to diet cards unless a resident requests otherwise, which was not the case here.
A facility failed to implement proper infection prevention practices during care for a cognitively impaired resident. A CNA, while assisting with incontinence care, did not change gloves before touching clean items and handled soiled laundry without bagging it. Interviews confirmed the CNA knew the correct procedures but was nervous, leading to the breach.
A resident with severe cognitive impairment and dementia was physically abused by another resident with similar impairments, resulting in a scalp laceration and severe pelvic fracture. The incident occurred after both residents were in the dining room and later assisted to their rooms. The perpetrator had recently undergone a dose reduction of antipsychotic medication.
Unlabeled and Unverified Medication Left in Resident’s Possession
Penalty
Summary
Surveyors identified a failure to ensure safe storage and proper labeling of medications for one resident reviewed for medication administration. Observation showed the resident had an unlabeled medication cup containing one unmarked white pill. The resident reported that a traveling nurse had given a sodium chloride “salt pill” a few months earlier, even though the resident knew they were prescribed sodium bicarbonate and refused to take the pill after noticing the difference. The resident stated the nurse told them it did not make a difference and that it did the same thing, and that the nurse left the medication behind after the resident refused it. Review of the medical record showed the resident had diagnoses including chronic kidney disease, hypertension, and atherosclerotic heart disease, and had a physician’s order for sodium bicarbonate 325 mg, two tablets by mouth twice daily for acute kidney failure, with no order for sodium chloride. There was no evidence of a self-administration of medication assessment in the record. The DON stated the medication in the resident’s possession was an OTC medication but was unable to verify what it was, when it was provided, or whether it had been documented on the MAR, and confirmed she expected nurses to watch residents take their medications. The regional clinical nursing director reported that the facility did not have a policy on medication administration.
Failure to Bag and Contain Soiled Linens Before Transport
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices for handling soiled linens on one of four units. On 4/30/26 at 6:01 AM, a CNA was observed exiting a resident room carrying unbagged, soiled bed linens in her hands, walking down the hallway, and placing the soiled linens directly into the dirty linen bin without first bagging them inside the room. In an interview later that morning, the DON confirmed that facility practice requires soiled linens to be placed in a bag before leaving the resident’s room. Review of the facility’s policy titled “Soiled Laundry and Bedding,” last revised in February 2026, showed that contaminated laundry is to be placed and transported in bags or containers in accordance with established policies governing the handling and disposal of contaminated items. This deviation from both staff-stated practice and written policy regarding the handling and transport of contaminated laundry constituted a failure to implement the facility’s infection prevention and control program on the affected unit.
Failure to Timely Report Injury of Unknown Source Involving Suspected Fracture
Penalty
Summary
The deficiency involves the facility’s failure to timely report an injury of unknown source to the State Agency within 2 hours as required by policy. A resident with non-Alzheimer’s dementia, anxiety, depression, and a BIMS score of 0 indicating severe cognitive impairment was noted on a quarterly MDS to have had no falls since admission or the prior assessment. On the evening in question, a progress note documented new or worsening edema and a change in skin color/condition of the resident’s right lower extremity, and the PCP recommended transfer to the ER for an x-ray to rule out fractures. Shortly thereafter, another progress note described mild bruising, visible swelling, and inward deformity of the right knee, with notification of the DON and MD and a recommendation to send the resident to the ER. The following day, the DON documented increased swelling and pain on touch, decreased ROM, non–weight-bearing status of the right lower extremity, and no open areas, with an order from the provider to send the resident to the ER to rule out fracture or dislocation of the right knee. The SSD reported that the DON notified administrative staff of the right knee injury at the morning staff meeting and that the SSD accompanied the resident and POA to the ER, where a right femur fracture was identified and communicated back to facility administration. The SSD further reported that an APS caseworker arrived later that day and stated she had not received a report from the facility, and the SSD was instructed to open the report. Review of the facility’s FRI showed the allegation of injury of unknown source occurred at 9:40 PM, staff and the administrator were made aware at 9:43 PM, but the initial incident report was not sent to the State Agency until 9:05 PM the following day, exceeding the 2-hour reporting requirement. Interviews with multiple CNAs indicated the resident had complained of pain and exhibited abnormal right knee findings for an extended period prior to the ER transfer. One CNA stated the resident had complained of pain for approximately two weeks and that she reported it to nurses daily. Another CNA reported that for about three weeks the resident’s right knee had been swollen, discolored with greenish-purplish bruising, and not normal, and that she informed nurses who responded they would give pain medication. A third CNA recalled the resident in mid-February moaning, groaning, and stating the leg was broken, which she reported to a nurse who then provided pain medication. A fourth CNA described the resident crying out in pain on the night of the incident, with the right leg appearing larger, bent, and discolored after transfer with a hoyer lift, which she reported to the nurse. LPN interview confirmed increased yelling out in pain that evening, subsequent discovery of the visibly deformed knee after CNA report, and notification of the DON, resident representative, and physician. Despite these findings and the facility policy requiring immediate reporting, but no later than 2 hours, of all allegations of abuse, neglect, exploitation, mistreatment, and injuries of unknown source that involve abuse or result in serious bodily injury, the facility did not report the injury of unknown source within the required timeframe.
Resident Discharged Without Provider-Signed Orders or Follow-Up Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and orderly discharge for a resident admitted for skilled rehabilitation and nursing care. The resident had diagnoses including nontraumatic hematoma of soft tissue, CHF, UTI, and mild cognitive impairment, and had been certified by the physician for a 30‑day skilled stay with a recommendation for post‑SNF care at an ALF. Care conference minutes identified an approximate discharge date of 10 days after admission. The medical record documented that the resident was discharged on 3/30/26 in the early afternoon, with an LPN note stating that discharge orders were received and carried out, vital signs were stable, discharge instructions and medications were reviewed with the resident and responsible party, and all belongings were sent with the resident, who left via personal transport in stable condition. However, interviews and documentation showed that no provider had actually issued or signed discharge orders at the time of discharge. The NP reported that the physician’s office had not received discharge orders, that the physician was out of town, and that she refused to sign requested orders for medications and therapy because she had not evaluated the resident and had not ordered the discharge. She further stated there was no discharge visit, no follow‑up physician visit scheduled, and no written PT/OT orders, and the discharge was not treated as an AMA discharge. The SSD stated staff believed they had physician orders because they had “lined everything up,” but only realized after the resident left that the physician had not been contacted, prompting a call for a narcotic prescription that the NP declined to sign. The NHA confirmed the expectation that a provider discharge order should be in place before discharge, and the regional director of clinical operations confirmed the resident was discharged without signed discharge orders.
Inadequate Supervision and Unsafe Hot Beverage Practices Leading to Burns and Accident Hazards
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision and appropriate devices to prevent accidents, particularly related to hot beverages. One resident with moderate cognitive impairment, a history of stroke, hemiplegia, hemiparesis with hand contractures, and dysphagia had a care plan requiring use of a Kennedy cup for all hot beverages and that food and fluids be served at non-scalding temperatures. Despite these interventions, the resident was given hot coffee in a Styrofoam cup without a lid during a period when the facility was using disposable dinnerware due to an influenza outbreak. The CNA who provided the coffee left the room to care for another resident, and the resident subsequently spilled the coffee into their lap, resulting in burns to the thighs that required ED evaluation and treatment. Surveyors identified additional concerns in the dining room where multiple residents independently accessed hot beverages from a coffee machine and water spout without lids or assistance. One resident independently obtained coffee in an open cup, placed it on a walker seat, and ambulated, causing the coffee to spill. Other residents independently obtained hot water from the coffee machine water spout into open cups and walked back to their tables while simultaneously pushing walkers, sometimes spilling coffee on themselves and tables, though without documented injury in those instances. Observations showed that residents were routinely allowed to obtain hot beverages on their own, often in open cups without lids, while using walkers. Further observations and staff interviews revealed that the water from the coffee machine measured 176.7°F and later 168.7°F, and dietary staff stated that water from the coffee machine was never supposed to be given directly to residents and that coffee and water temperatures were checked in the kitchen and not to be served directly from the machine. A CNA reported that residents were allowed to independently obtain beverages, that there was supposed to be two aides in the dining room prior to meals but usually only one was present, and that she was unaware of any interventions to prevent residents from filling cups from the coffee machine. She also stated that specialty adaptive items were identified on meal trays, but beverages were usually provided before trays came out, contributing to residents independently accessing hot beverages. These combined actions and inactions led to the determination of immediate jeopardy related to accident hazards and inadequate supervision.
Failure to Prevent Resident-on-Resident Physical Abuse Between Cognitively Impaired Roommates
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when two cognitively impaired roommates engaged in a physical altercation. One resident had severely impaired memory, verbal behavioral symptoms directed toward others, and a diagnosis of non-Alzheimer’s dementia. The roommate had moderate cognitive impairment with a BIMS score of 10/15 and diagnoses including dementia and anxiety. On the day of the incident, a CNA had taken the first resident into the shared room to watch television while the roommate was on their side of the room looking through personal belongings. After the CNA briefly left for the nurses’ station, loud noises were heard coming from the room. When the CNA returned, both residents were next to each other, with the first resident holding a fist up and the roommate holding a Bible raised toward the first resident. Both residents stated they had been fighting, and the roommate said the other was “in the way.” The CNA and RN observed blood and scratches on the first resident’s face, and assessment revealed two small abrasions to the left cheek. The roommate had no injuries. Staff interviews confirmed that the altercation occurred between the two roommates and that the injured resident required cleaning of the facial abrasion. This sequence of events constituted a failure to ensure the resident’s right to be free from physical abuse by another resident.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property for one of the residents reviewed for abuse, neglect, and misappropriation. The resident, who was cognitively intact with a mental status score of 14 out of 15, reported to a housekeeper that $200 was missing from a bank envelope on their bedside table. The resident was unable to specify what happened to the money or when it went missing. Despite the resident informing the social services director about the missing money, the allegation was not reported to the state survey agency as required. The facility's policy on reporting and investigating abuse, neglect, exploitation, or misappropriation mandates that any suspicion must be reported immediately to the administrator and other officials according to state law. The policy specifies that allegations not involving abuse or serious bodily injury should be reported within 24 hours. However, the social services director confirmed that the investigation into the missing money was completed but not reported to the state survey agency, indicating a failure to adhere to the facility's policy and state reporting requirements.
Failure to Engage Resident in Activities Program
Penalty
Summary
The facility failed to provide an activities program that met the needs and preferences of a resident with dementia and behavioral symptoms. The resident, who had a history of being a janitor and enjoyed being helpful, was observed pacing and not being engaged in activities as per their care plan. The care plan indicated the resident's interest in group activities, going outside, and participating in simple, structured activities. However, observations showed the resident was not assisted to participate in scheduled activities and was left to pace around the facility. On multiple occasions, the resident was observed pacing in the dining room and hallways without being engaged in any activities. Despite the activities calendar listing various activities, the resident was not invited or assisted to join them. The resident expressed a desire to help with cleaning tasks, but staff did not facilitate this interest, leaving the resident to attempt cleaning tasks independently without proper support or guidance. The facility's policy stated that activities should be based on comprehensive resident-centered assessments and preferences, yet the resident's needs were not met. The social services director acknowledged that the facility was short-staffed due to one activities staff member being on medical leave and another on vacation, which affected the implementation of the activities program. The expectation was for CNAs to perform structured activities, but this was not observed during the survey.
Failure to Follow Diabetic Diet Orders
Penalty
Summary
The facility failed to adhere to the dietary orders for a resident with diabetes mellitus, who was on a controlled carbohydrate diet. The resident, who was cognitively intact, was supposed to receive a half portion of a cinnamon roll without glaze, as per the diet card accompanying the meal. However, during an observation, the resident was served a full cinnamon roll with glaze, contrary to the prescribed diet. The resident confirmed that the facility did not follow the diabetic diet plan. Interviews with the dietitian and dietary manager revealed that the facility's diabetic diet protocol includes smaller portions of carbohydrates and sugar, and diet cards should be strictly followed unless a resident requests a deviation. The dietary manager confirmed that any requests for different items should be noted on the diet card, and in this case, the resident did not request a full cinnamon roll or glaze. The dietary manager also stated that aides are expected to catch such discrepancies and seek nurse approval if a resident requests a full portion, which did not occur in this instance.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to implement proper infection prevention practices during personal care for a resident with severe cognitive impairment and physical disabilities. The resident, who was frequently incontinent and dependent on staff for hygiene, was observed being assisted by a CNA and an OT. During the care, the CNA placed the resident's soiled pants on the floor and proceeded to perform incontinence care. Without changing gloves, the CNA touched various clean items in the room, including the resident's clean clothing and personal items, before finally removing the gloves and using hand sanitizer. The CNA then handled the soiled pants without placing them in a bag, contrary to infection control protocols. Interviews with the CNA and the infection preventionist confirmed that the CNA was aware of the expectation to remove contaminated gloves before touching clean items and to bag soiled items before leaving the resident's room. The facility's policies and CDC guidelines were reviewed, which clearly outlined the proper procedures for glove use and handling of soiled laundry. The CNA admitted to being nervous, which contributed to the failure to follow these protocols, resulting in a breach of infection prevention practices.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in actual harm. The victim, who had severely impaired cognitive skills and a history of non-Alzheimer's dementia and pelvic fractures, was found on the floor of their room with a scalp laceration after being pushed by another resident. This incident occurred after both residents had been in the dining room together and were later assisted to their rooms. The perpetrator, also with severely impaired cognitive skills and a history of unspecified dementia with behavioral disturbances, entered the victim's room and admitted to pushing them down. The incident was discovered when a CNA heard a door slam and found the victim on the floor with a head injury. The victim was subsequently diagnosed with a severe pelvic fracture and exacerbation of degenerative joint disease. Interviews with staff revealed that the incident was unexpected, as the residents had been getting along well prior to the event. The perpetrator had recently undergone a gradual dose reduction of antipsychotic medication, which was increased following the incident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Worland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wyoming Retirement Center | 24.6 mi | — | 1 | 0 |
| Thermopolis Rehabilitation And Wellness | 29.4 mi | — | 11 | 0 |
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