Worland Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Worland, Wyoming.
- Location
- 1901 Howell Ave, Worland, Wyoming 82401
- CMS Provider Number
- 535048
- Inspections on file
- 20
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 6 (1 serious)
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.
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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