cms_WY
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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid ▼ | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3226 | 3226 | SHEPHERD OF THE VALLEY HEALTHCARE CENTER | 535042 | 60 MAGNOLIA | CASPER | WY | 82604 | 2011-07-12 | 309 | E | 1 | 0 | 023V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview and medical record review, the facility failed to ensure all necessary assessments, monitoring, and nursing measures (including non-pharmacologic intervention) were implemented for preventive pain management for 4 of 5 sample residents (#2, #14, #96, #157) who had pain. The findings were: 1. Review of the medical record for resident #96 showed s/he had [DIAGNOSES REDACTED]. Review of the 4/27/11 pain assessment showed the resident had constant pain. Review of the resident's 5/9/11 admission MDS assessment showed the resident had pain in the past five days with an intensity rating of 7 out of 10 (7/10) on a pain scale of 0 to 10 with 10 being the worst. Review of physician's orders [REDACTED]. Review of the June 2011 MAR indicated [REDACTED] a. Review of the June 2011 showed this resident received [MEDICATION NAME] 10/500 mg one-half tablet 23 times for complaint of leg pain. Twenty-one of the 23 times, 91%, the resident's pain was not re-assessed to determine the effectiveness of the pain medication. In addition, the resident received one whole tablet of Vicodan 10/500 mg 23 times for pain. Of those 23 times, the resident did not have his/her pain re-assessed to determine the effectiveness of the medication in relieving the pain 16 times (69.5%). b. On 6/9/11 at 9:30 AM, based upon a statement from the restorative aide, the resident received one whole tablet of Vicodan 10/500 mg for leg pain. Review of the medical record showed no evidence the nurse assessed the resident's pain at that time, only that she administered the medication. In addition, there was no evidence the resident's pain was re-assessed to determine the effectiveness of the medication. c. Tylenol 650 mg was administered to the resident for pain nine times in June 2011. Additionally, review showed that eight of the nine times, 89%, there were no re-assessments performed to determine the effectiveness of the pain medications. d. The residen… | 2014-11-01 |
| 3227 | 3227 | SHEPHERD OF THE VALLEY HEALTHCARE CENTER | 535042 | 60 MAGNOLIA | CASPER | WY | 82604 | 2011-07-12 | 514 | D | 1 | 0 | 023V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure medical record notations were accurate in regard to medication administration for 3 of 5 sample residents (#2, #14, #96). The findings were: 1. Review of the June 2011 MAR for resident #2 showed on 6/4/11 and on 6/19/11 the resident received a Tylenol 650 milligrams (mg) for pain. However, the times were not documented. On 6/17/11 the resident received [MEDICATION NAME] 100 mg for pain but the time was not documented. 2. Review of the June 2011 MAR for resident #14 showed on 6/23/11 the resident was administered a [MEDICATION NAME] 7.5/325 mg narcotic for pain. Continued review showed the time was not documented. 3. Review of the June 2011 MAR for resident #96 showed s/he received Vicodan (narcotic) 10/500 mg and [MEDICATION NAME] (skeletal muscle relaxant) 5 mg for leg pain on 6/1/11. Review also showed the time of administration was not documented. 4. During an interview on 7/12/11 at 9 AM, the assistant director of nursing confirmed there was a problem with completing the PRN flowsheets in regard to medications. | 2014-11-01 |
| 3125 | 3125 | SHEPHERD OF THE VALLEY HEALTHCARE CENTER | 535042 | 60 MAGNOLIA | CASPER | WY | 82604 | 2011-10-19 | 309 | G | 1 | 0 | 02CC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review, the facility failed to ensure nursing assessment and monitoring was adequately provided to recognize the early signs and symptoms of a [MEDICAL CONDITION] for 1 of 1 sample residents (#167) who sustained a head injury (subarachnoid hemorrhage). In addition, 4 of the 8 medical records reviewed (#11, #101, #132, #167) revealed post fall assessments were incomplete and/or there were missed vital signs. The findings were: 1. Review of the nursing note dated 10/1/11 and interview with RN #1 on 10/18/11 at 5:30 PM revealed the following sequence of events: Resident #167 injured his/her head when s/he fell in the TV room on 10/1/11 at 7 AM. The initial post fall assessments at 7 AM and 7:15 AM revealed the resident's vital signs and neurological assessments were within normal parameters. At that time the nursing staff began to record the neurological assessment and vital signs on the neurological assessment form as directed by the facility's policy and protocol for falls resulting in a head injury. This protocol included assessments every fifteen minutes for the first hour, every thirty minutes for two hours, every hour for four hours, every four hours for eight hours, and every eight hours for forty-eight hours. The timed neurological assessments were to include vital signs and assessments of pupil responses, mental status, and extremity movements. However, from 7:15 AM until 10 PM that day (fourteen and a half hours), the resident's vital signs were only taken at 9 AM and 6 PM; the neurological assessments were not performed. In addition, there was no documentation regarding the description of the injured area on the resident's head. During the interview with RN #1, she stated the assessments and documentation were not done due to staff reassignments and "staff were busy that day." Review of the 10/2/11 nursing notes and interview with LPN #1 on 10/18/11 at 10:45 AM revealed the following sequenc… | 2015-02-01 |
| 3126 | 3126 | SHEPHERD OF THE VALLEY HEALTHCARE CENTER | 535042 | 60 MAGNOLIA | CASPER | WY | 82604 | 2011-10-19 | 520 | E | 1 | 0 | 02CC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to revise their QAPI program to ensure identified problems regarding post fall assessments and early recognition of the signs and symptoms of [MEDICAL CONDITION] were addressed appropriately. In addition, mandatory education was not provided for 3 of 8 nursing staff (LPN #2, CNA #2, CNA #3) whose attendance records were reviewed; nor was a system implemented in the QAPI program for ensuring all staff received the mandatory education. The findings were: Review of the nursing note dated 10/1/11 and interview with RN #1 on 10/18/11 at 5:30 PM revealed the following sequence of events: Resident #167 injured his/her head when s/he fell in the TV room on 10/1/11 at 7 AM. The initial post fall assessments at 7 AM and 7:15 AM revealed the resident's vital signs and neurological assessments were within normal parameters. At that time the nursing staff began to record the neurological assessment and vital signs on the neurological assessment form as directed by the facility's policy protocol for falls resulting in a head injury. This protocol included assessments every fifteen minutes for the first hour, every thirty minutes for two hours, every hour for four hours, every four hours for eight hours, and every eight hours for forty-eight hours. The timed neurological assessments were to include vital signs and assessments of pupil responses, mental status, and extremity movements. However, from 7:15 AM until 10 PM that day (fourteen and a half hours), the resident's vital signs were only taken at 9 AM and 6 PM; the neurological assessments were not performed. In addition, there was no documentation regarding the description of the injured area on the resident's head. During the interview with RN #1, she stated the assessments and documentation were not done due to staff reassignments and "staff were busy that day." Review of the 10/2/11 nursing notes and interview with LPN #1 on 10/18/11 at 10:45 AM revealed the following sequence of… | 2015-02-01 |
| 227 | 227 | CHEYENNE HEALTH CARE CENTER | 535025 | 2700 E 12TH STREET | CHEYENNE | WY | 82001 | 2019-08-15 | 645 | D | 0 | 1 | 03QU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the pre-admission screening and resident review (PASARR) process was accurately completed for 1 of 2 sample residents (#66). The findings were: Review of the medical record showed resident #66 had a [DIAGNOSES REDACTED]. In addition, review of the (MONTH) 2019 MAR indicated [REDACTED]. The following concerns were identified: a. Review of the PASARR level 1 dated 6/9/19 showed this [DIAGNOSES REDACTED]. b. Interview with the social worker on 8/14/19 at 12:14 PM revealed the [DIAGNOSES REDACTED]. The social worker further revealed the physician wrote an order dated 8/14/19 to change the [DIAGNOSES REDACTED]. | 2020-09-01 |
| 228 | 228 | CHEYENNE HEALTH CARE CENTER | 535025 | 2700 E 12TH STREET | CHEYENNE | WY | 82001 | 2019-08-15 | 725 | E | 1 | 1 | 03QU11 | > Based on resident interview, family interview, staff interview, review of daily nurse staff postings, and review of hours per patient per day requirements (HPPD), the facility failed to ensure sufficient nursing staff to meet resident needs for 2 of 2 units (South, North). The census was 89. The findings were: Review of daily nurse staff postings from 8/1/19 through 8/13/19 showed the facility posted actual hours worked and the number of staff for each nursing category which included CNAs, LPN-LVNs, and RNs. The postings also showed the daily census. Review of the facility-determined HPPD for each nursing staff category showed 1.713 HPPD were required for CNAs, 0.306 HPPD were required for LVNs/LPNs, and 0.4355 HPPD were required for RNs. The review showed the HPPD were not separated per unit and reflected the facility as a whole. The following concerns were identified: 1. Concerns from nurse staff postings from 8/1/19 through 8/13/19: a. The review showed the facility determined ratio of 1.713 HPPD for CNAs was not met for 6 of the 13 days (8/3/19, 8/4/19, 8/6/19, 8/8/19, 8/10/19, 8/11/19). Four of those 6 days were on the weekend. b. The review showed the facility determined ratio of 0.306 HPPD for LVN-LPNs was not met for any of the 13 days reviewed. c. The review showed the facility determined ratio of 0.4355 HPPD for RNs was not met for 6 of the 13 days (8/1/19, 8/2/19, 8/6/19, 8/7/19, 8/8/19, 8/9/19). 2. Concerns from resident interviews: a. Interview with resident #84 on 8/12/19 at 11:06 AM revealed staff took from 30 to 40 minutes to answer call lights. b. Interview with resident #187 on 8/12/19 at 10:23 AM revealed call lights were not answered promptly. S/he stated it had taken up to an hour for staff to answer call lights. S/he further stated staff would sometimes peek in the door and say they would return. However, staff would not return for up to an hour. c. Interview with resident #44 on 8/12/19 at 3:45 PM revealed s/he felt the facility needed more help, so more than one resident at a time could … | 2020-09-01 |
| 229 | 229 | CHEYENNE HEALTH CARE CENTER | 535025 | 2700 E 12TH STREET | CHEYENNE | WY | 82001 | 2019-08-15 | 756 | D | 1 | 1 | 03QU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to ensure a medication irregularity was reported to the DON, medical director, and attending physician for 1 of 3 sample residents (#37) reviewed for pain management. The findings were: 1. Review of the medical record for resident #37 showed s/he was admitted to the facility on [DATE] with allergies [REDACTED]. The following concerns were identified: a. Review of the most current physician orders [REDACTED]. Further review showed the order for the Tylenol was communicated via phone. b. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. c. Review of the (MONTH) 2019 MAR from 8/1/19 through 8/12/19 showed [MEDICATION NAME] was administered 1 time. d. Review of the drug regimen review dated 8/1/19 showed This medical record has been reviewed with no recommendations or irregularities noted at this time. e. Interview with the DON on 8/15/19 at 8:57 AM revealed if the allergy was not a true allergy the physician would have addressed it in a progress note when he prescribed it. In addition, the nurses should have recognized the irregularity before administering the medication. f. Interview with the director of regulatory compliance on 8/15/19 at 10:13 AM revealed the pharmacist should have identified the irregularity. g. The facility's pharmacist was unresponsive to multiple attempts to contact him for an interview. | 2020-09-01 |
| 230 | 230 | CHEYENNE HEALTH CARE CENTER | 535025 | 2700 E 12TH STREET | CHEYENNE | WY | 82001 | 2019-08-15 | 880 | D | 0 | 1 | 03QU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy and procedure review, the facility failed to ensure effective infection control practices were followed during 2 random resident observations (#75, #82). The findings were: 1. Observation on 8/12/19 at 12:30 PM showed the DON performed a dressing change for resident #75. The following concerns were identified: a. After the DON finished the removal of the old dressings, cleaned the wounds, and measured the wound she failed to remove her gloves, perform hand hygiene, and don clean gloves before applying the new dressing. b. Interview with the Infection Control nurse on 8/15/19 at 9:30 AM revealed the expectation was for the nurse to change gloves after removing the old dressing and putting on the new dressing. c. Review of policy and procedure titled Alginate dressing application last revised on 2/15/19 showed .Clean the wound . Remove and discard your gloves. Perform hand hygiene. Put on a new pair of clean or sterile gloves .Assess wound severity . 2. Review of the 5/20/19 quarterly MDS assessment showed resident #82 had [DIAGNOSES REDACTED]. Review of the 7/3/19 care plan showed the resident had a history of [REDACTED]. a. Observation on 8/13/19 at 1:05 PM showed the resident was in his/her wheelchair in front of the building. The catheter bag was noted to be attached to the back of the wheelchair hanging at shoulder level with urine visible in the tubing. b. Interview with the infection control nurse on 8/15/19 at 10:07 AM confirmed the catheter bag should not be held above the level of the bladder. | 2020-09-01 |
| 1083 | 1083 | GRANITE REHABILITATION AND WELLNESS | 535013 | 3128 BOXELDER DRIVE | CHEYENNE | WY | 82001 | 2016-11-10 | 203 | D | 1 | 0 | 043F11 | > Based on medical record review, and family and staff interview, the facility failed to ensure the discharge notice included all required information for 1 of 4 sample residents (#45) who received a discharge notice. The findings were: 1. Review of a discharge notice dated 10/26/16 showed the facility intended to discharge resident #45 on 11/28/16 due to it is necessary to meet the resident's welfare and the resident's welfare cannot be met in the center. The following concerns were identified: a. Further review of the 10/26/16 discharge notice showed the discharge could be appealed to the staff designee for the facility's grievance policy . and, if not resolved, You can continue your appeal to the nursing facility's grievance committee. The discharge notice did not indicate the resident or his/her representative had the right to appeal the discharge action to the State. b. Interview with the resident's spouse on 11/10/16 at 2:05 PM revealed a care conference was conducted after the discharge notice was issued. Family asked about appeal at that time and were told not to bother because the appeal would be reviewed by the same people that were in the care conference and the result would not change. The spouse also revealed the resident could not return home because the home had been determined to be unsafe and the spouse's health was deteriorating. c. Interview with another family member on 11/10/16 at 3:15 PM revealed the facility basically told us there was no such thing (as an outside appeal of the discharge). Further, it was revealed when the family asked what they could do, they were told by the administrator It's clearly stated in that letter what you need to do. d. Interview with the DON, administrator, and social services director on 11/10/16 at 3:40 PM confirmed the information on the discharge letter did not include all of the required information. | 2019-11-01 |
| 1290 | 1290 | AMIE HOLT CARE CENTER | 53A002 | 497 W LOTT | BUFFALO | WY | 82834 | 2015-12-03 | 309 | E | 0 | 1 | 044H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of policies and procedures, the facility failed to ensure PRN (as needed) medication was effective to treat symptoms for 5 of 5 sample residents (#14, #16, #20, #24, #40) who received PRN medication. The findings were: 1. Review of the 8/27/15 significant change MDS assessment for resident #16 revealed s/he exhibited indicators of pain daily, including non-verbal signs, vocal complaints, facial expressions, and protective body movements. Review of the care plan (printed 12/1/15) revealed the resident had pain. Review of physician orders [REDACTED]. Review of the MAR for 11/1/15 to 12/1/15 showed the resident was administered the PRN medication 25 times. Further review of the MAR and the medical record showed no evidence the effectiveness of the medication was documented for any of the 25 administrations. 2. Review of the 11/23/15 significant change MDS assessment showed resident #14 had moderate pain frequently. Review of a physician's note dated 11/17/15 revealed the resident had [MEDICAL CONDITION], was on a [MEDICATION NAME] (an opiod pain medication) and had PRN pain medications for breakthrough pain. Review of the care plan (printed 12/1/15) showed the resident had pain. The goal for pain was: will have decreased pain, to a level acceptable to res (resident) within 30 to 45 minutes of administration of pain-relieving med (medication). Review of physician's orders [REDACTED]. Review of the MAR for 11/1/15 to 12/1/15 revealed the following: a. The resident received 5 mg of [MEDICATION NAME] oral concentrate 20 mg/mL PRN 30 times. Of the 30 times, the effectiveness of the pain medication was only documented 9 times. b. The resident was administered PRN 10 mg of [MEDICATION NAME] oral concentrate 20 mg/mL 46 times. The effectiveness of the medication was only documented for 14 of the 46 administrations. 3. Review of the 9/2/15 annual MDS assessment revealed resident #40 had moderate… | 2019-07-01 |
| 1291 | 1291 | AMIE HOLT CARE CENTER | 53A002 | 497 W LOTT | BUFFALO | WY | 82834 | 2015-12-03 | 315 | D | 0 | 1 | 044H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and staff and family interviews, the facility failed to obtain a urine sample in a timely manner to identify and treat a suspected urinary tract infection [MEDICAL CONDITION] for 1 of 1 sample resident (#43) treated for [REDACTED]. 1. Review of a nursing note dated 10/22/15 for resident #43 revealed the resident's daughter told the nurse the resident was acting like s/he did the last time s/he had a UTI. The nurse noted the resident had a fever the previous night and stated s/he didn't feel well. The daughter requested a UA (urinalysis). The nurse documented a UA would be done in the morning. The following concerns were identified: a. Further review of the medical record showed the urine sample was not collected until 10/27/15 (5 days later) via catheterization. b. The only nursing note between 10/22/15 and 10/27/15 was made on 10/26/15 and indicated the nurse was unable to collect a sample list because the resident was not feeling well. c. Review of the 10/27/15 UA results showed the urine was cloudy and many bacilli were present. d. Review of physician orders [REDACTED]. The physician also ordered a culture. Review of the culture dated 10/29/15 showed Alpha strep. present- no further workup. A nursing note dated 10/29/15 showed the physician received the results of the culture and wished to continue the antibiotic. e. During an interview on 12/2/15 at 10:35 AM the resident's family member stated it shouldn't take 6 days to get a sample. f. On 12/2/15 at 4:15 PM team leader #1 stated the facility had a difficult time getting a clean catch urine sample on the resident, and finally got a sample via catheterization on 10/27/15. She also stated this occurred over a weekend, and lab was not always available. g. Review of standing physician orders [REDACTED]. Mini catheterization procedure on residents who unable to do a clean catch procedure. h. During an interview on 12/3/15 at 8:34 AM the infection control coordi… | 2019-07-01 |
| 1271 | 1271 | ROCKY MOUNTAIN CARE - EVANSTON | 535038 | 475 YELLOW CREEK ROAD | EVANSTON | WY | 82930 | 2016-02-25 | 176 | D | 0 | 1 | 06BH11 | Based on observation, staff and resident interview, and medical record review, the facility failed to ensure an assessment was completed for safe self-administration of medications for 1 of 9 sample residents (#36). The findings were: Review of the 12/17/15 quarterly MDS assessment showed resident #36 was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 14/15. Observation on 2/22/16 at 6 PM showed the resident was eating in his/her room and had a medication cup containing multiple pills located on the meal tray. Interview with the resident at that time revealed the nurse had left the medications, and the resident wondered if his/her pain medication was included. Interview with LPN #1 on 2/22/16 at 6:05 PM verified the medications had been left with the resident, and the pain medication was included. She then verified she should have stayed and ensured the resident took the medications. Interview with the DON on 2/24/16 at 10:45 AM verified nurses were expected to watch residents take medications, and there was no assessment completed for the resident related to self-administration. | 2019-07-01 |
| 1272 | 1272 | ROCKY MOUNTAIN CARE - EVANSTON | 535038 | 475 YELLOW CREEK ROAD | EVANSTON | WY | 82930 | 2016-02-25 | 225 | D | 0 | 1 | 06BH11 | Based on review of policies and procedures, and facility investigation documentation, and staff interview, the facility failed to ensure resident safety during the investigation for 1 of 3 allegations of staff to resident abuse reviewed (resident #34). The findings were: 1. Review of facility investigation documentation showed an allegation of mistreatment involving resident #34 occurred on 6/9/15. An LPN was accused of jerking the resident up in bed and hurting his/her arm. Review of the facility's documentation showed staff were told to always have a second staff person present when caring for resident #34. There lacked evidence the facility protected other residents from potential abuse by the LPN during the investigation. The results of the investigation were dated 6/12/15; the facility determined the allegation was unsubstantiated. 2. During an interview on 2/25/16 at 8:16 AM, the administrator stated the LPN was not suspended or removed from direct resident contact during the investigation. She stated she did not do that because the assessment of the resident after the incident did not reveal any injuries to the arm. 3. Review of the facility's policy Abuse- Prevention, Investigating and Reporting (#2001, revised 6/2009) revealed .Protection .If the complaint alleges abuse by a staff member, that staff member will be suspended or removed from direct patient care (whichever is appropriate to protect the resident) until an investigation has been completed . | 2019-07-01 |
| 1273 | 1273 | ROCKY MOUNTAIN CARE - EVANSTON | 535038 | 475 YELLOW CREEK ROAD | EVANSTON | WY | 82930 | 2016-02-25 | 244 | E | 0 | 1 | 06BH11 | Based on review of resident group meeting minutes, and staff and resident interview, the facility failed to ensure grievances from the resident group were acted upon to resolve repeated issues for 3 of 3 months (December (YEAR), (MONTH) (YEAR), (MONTH) (YEAR)) reviewed. The findings were: Review of the resident council meeting minutes for (MONTH) (YEAR), and (MONTH) and (MONTH) (YEAR) showed there were issues that were unresolved. These issues included the need for more staff to answer call lights timely, the need for added assistance/coverage in the dining room for the evening meal, and to have nurses stay in the room to ensure residents took their medications. Confidential interview with a group of residents on 2/23/16 revealed of the 9 residents who attended the group interview, 7 felt these issues had not improved. Interview with the resident advocate on 2/24/16 at 9:50 AM revealed the process for addressing resident council grievances/issues was for the administrator to respond in e-mail. The advocate received the e-mail and then relayed the information to the residents at the next meeting. The advocate confirmed the process was not always effective, and repeat issues had been brought up. | 2019-07-01 |
| 1274 | 1274 | ROCKY MOUNTAIN CARE - EVANSTON | 535038 | 475 YELLOW CREEK ROAD | EVANSTON | WY | 82930 | 2016-02-25 | 253 | E | 0 | 1 | 06BH11 | Based on observation and staff interview, the facility failed to ensure handrails were maintained in 3 of 3 resident hallways (100 hallway, 200 hallway, 300 hallway). In addition, the facility failed to ensure resident floors were maintained to ensure adequate cleaning for the television area (connected to the main dining area) and 3 of 3 hallways (100 hallway, 200 hallway, 300 hallway). The findings were: 1. Observation on 2/25/16 at 10 AM showed the following handrails had various scratches and scrapes: a. In the hallway by room #103. b. In the hallway by room #104. c. In the hallway by room #105. d. In the hallway between rooms #300 and #302. e. In the hallway across from the nursing station by room #200. f. In the hallway across from the nursing station by the beauty shop. g. In the hallway across from the nursing station by the custodial closet. 2. Observation on 2/25/16 from 8:15 AM through 9 AM showed the following concerns with damaged floors that created a surface inadequate for cleaning: a. The floor between the doorway of room #100 and the hallway had a noticeable gap 42 inches in length which was darkened with dirt and debris. b. The floor at the front of room #105 had 2 tiles that measured 12 by 12 inches with a 6 inch noticeable crack that was darkened with dirt. c. The floor between the doorway of room #106 and the hallway had a noticeable gap 42 inches in length which was darkened with dirt and debris. d. The floor between the doorway of room #107 and the hallway had a noticeable gap 32 inches in length which was darkened with dirt and debris. e. The floor between the doorway of room #110 and the hallway had a noticeable gap 42 inches in length which was darkened with dirt and debris. f. The floor at the front of room #200 had 1 tile that measured 12 by 12 inches with a 6 inch noticeable crack that was darkened with dirt. g. The floor between the doorway of room #201 and the hallway had a noticeable gap 32 inches in length which was darkened with dirt and debris. h. The floor at the front of room … | 2019-07-01 |
| 1275 | 1275 | ROCKY MOUNTAIN CARE - EVANSTON | 535038 | 475 YELLOW CREEK ROAD | EVANSTON | WY | 82930 | 2016-02-25 | 309 | D | 0 | 1 | 06BH11 | Based on medical record and staff interview, the facility failed to ensure 1 of 1 sample resident (#13) who had a fall with a head injury received neurological checks (neuro-checks). The findings were: Medical record review for resident #13 showed s/he had a fall on 2/8/16 at 2:30 PM. Review of the corresponding post-fall assessment showed the following under the team meeting notes, Per nurse resident lost (his/her) balance and fell in (his/her) room. Blood sugar 93. Slightly raised area to right posterior cranium. Review of the entire medical record showed no documentation of any neuro-checks after the resident's fall. Interview with the DON on 2/24/16 at 5:30 PM confirmed the facility failed to perform neuro-checks on the resident after the 2/8/16 fall. She further confirmed her expectation was for facility staff to perform neuro-checks any time a resident has an injury to his or her head. According to Lippincott Nursing Procedures, Seventh Edition 2014 by Wolters Kluwer; after a fall, Determine whether the patient experienced a head trauma, which requires further diagnostic evaluation to rule out subdural hematoma .Even if the patient shows no signs of distress or has sustained only minor injuries, monitor his vital signs and assess his neurological status frequently until his condition stabilizes. Notify the practitioner if you note any change from the baseline. | 2019-07-01 |
| 1276 | 1276 | ROCKY MOUNTAIN CARE - EVANSTON | 535038 | 475 YELLOW CREEK ROAD | EVANSTON | WY | 82930 | 2016-02-25 | 315 | D | 0 | 1 | 06BH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to an indwelling the catheter was clinically necessary for 1 of 2 sample residents (#29) with indwelling catheters. The findings were: Observation on 2/22/16 at 4:44 PM revealed resident #29 was in bed, with a catheter drainage bag attached to the side of the bed. Review of the 10/28/15 admission and 1/28/16 quarterly MDS assessments revealed the resident had an indwelling catheter. Review of the Care Area Assessment (CAA) associated with the admission MDS assessment showed the resident had a catheter related to impaired mobility and incontinence as evidenced by need for foley catheter to prevent skin breakdown. Review of physician progress notes [REDACTED]. During an interview on 2/24/16 at 4:45 PM, the ADON stated if residents are admitted to the facility with it (catheter) in, we can leave it in. On 2/24/16 at 5:30 PM the DON stated they didn't evaluate catheters for appropriate use if they were present upon admission. | 2019-07-01 |
| 1277 | 1277 | ROCKY MOUNTAIN CARE - EVANSTON | 535038 | 475 YELLOW CREEK ROAD | EVANSTON | WY | 82930 | 2016-02-25 | 371 | F | 0 | 1 | 06BH11 | Based on observation and staff interview, the facility failed to ensure food and food service equipment was stored/prepared under sanitary conditions in 2 of 2 kitchens (activity room kitchen, main kitchen). The findings were: 1. Observations of the activity room kitchen on 9/23/16 at 9:10 AM showed the oven, microwave, and small refrigerator were in need of cleaning. The equipment was soiled with food debris on the interior and exterior surfaces. In addition, the small refrigerator with containers of pudding in it was not equipped with a thermometer. Further, the large refrigerator in this kitchen contained food items which were not dated to show when they were to be discarded. These items included buns, a partial bag of shredded lettuce, two shell eggs, and an opened bag of shredded cheese. Observation on 2/24/16 at 3:35 PM showed the condition of the equipment remained soiled, and some of the undated food items had been removed. According to Food Code 2013, U.S. Public Health Service: 3-501.17 (A) .refrigerated, READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. According to Food Code 2013, U.S. Public Health Service: 4-601.11 (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to Food Code 2013, U.S. Public Health Service: 4-204.112 . (B) Except as specified in (C) of this section, cold or hot holding EQUIPMENT used for TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be designed to include and shall be equipped with at least one integral or permanently affixed TEMPERATURE MEASURING DEVICE that is located to allow easy viewing of the device's temperature … | 2019-07-01 |
| 1278 | 1278 | ROCKY MOUNTAIN CARE - EVANSTON | 535038 | 475 YELLOW CREEK ROAD | EVANSTON | WY | 82930 | 2016-02-25 | 431 | D | 0 | 1 | 06BH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure medications available for use were not available past the expiration date in 2 of 3 storage areas (Group I medication cart, Group II medication cart). The findings were: 1. Observation on [DATE] at 9:25 AM with RN #1 showed the Group I medication cart had 24 tablets of Phenergan 25 mg (anti-emetic) with an expiration date of [DATE] that was available for use for resident #31. At that time RN #1 confirmed the medication was expired and available for use. 2. Observation on [DATE] at 9:40 AM with LPN #2 showed the Group II medication cart had 21 tablets of Zofran 8 mg (anti-emetic) with an expiration date of [DATE] that was available for use for resident #8. At that time LPN #2 confirmed the medication was expired and available for use. According to Clinical Nursing Skills 7th edition by Smith, Duell, and Martin; the six rights of medication administration includes the right medication, Compare drug container label to the medication sheet (MAR) three times. Note expiration date . | 2019-07-01 |
| 1279 | 1279 | ROCKY MOUNTAIN CARE - EVANSTON | 535038 | 475 YELLOW CREEK ROAD | EVANSTON | WY | 82930 | 2016-02-25 | 465 | D | 0 | 1 | 06BH11 | Based on observation and staff interview, the facility failed to ensure a safe and sanitary environment in 1 of 1 dish rooms. The findings were: Observation of the dish room on 2/24/16 at 11:15 AM showed the wall behind the sprayer had black grime which covered an area approximately 2 feet long by 6 inches in height. In addition, the dish room ceiling vents had visible dust on and around them, and the partition wall between the dirty and clean side of the room was soiled with food debris and had a corner piece missing. Interview with the dietary manager and the maintenance director on 2/24/16 at 4:50 PM verified these areas needed to be cleaned and/or repaired. | 2019-07-01 |
| 713 | 713 | WORLAND HEALTHCARE AND REHABILITATION CENTER | 535048 | 1901 HOWELL AVENUE | WORLAND | WY | 82401 | 2019-08-01 | 565 | E | 0 | 1 | 07FS11 | Based on resident and staff interview, review of resident council meeting minutes, review of the facility grievance log, and review of policies, the facility failed to act upon group grievances for 3 of 3 months of meeting minutes reviewed (May, June, July). The following concerns were identified: 1. Group interview with 9 residents on 7/30/19 at 11 AM revealed 2 of the 7 residents knew how to file a grievance, and the group felt the facility did not always follow up with them after voicing concerns. The following concerns were identified: a. Review of the resident council meeting minutes for (MONTH) 2019 showed the resident council voiced concerns related to slow meal service, talking amongst staff during meal service, missing resident clothing, bugs in the facility, and a television not getting turned off. Review of the resident council meeting minutes for (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019 showed no evidence the concerns were acted on or resolution was provided to the residents. b. Review of the resident council meeting minutes for (MONTH) 2019 showed there were concerns related to hand towels and wash cloths being available on hall 3, meal time, staff standing around while talking about family issues, and a television not being turned off. Review of the resident council meeting minutes for (MONTH) 2019, and (MONTH) 2019 showed no evidence the concerns were acted on or resolution was provided to the residents. c. Review of the resident council meeting minutes for (MONTH) 2019 showed the resident council voiced concerns related to missing clothes and a damaged toilet. Further review showed no evidence the concerns were acted on or resolution was provided to the residents. d. Review of the grievance log for (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019 showed no evidence of the concerns from resident council or resolution related to the concerns. e. Interview with the social services director (SSD) on 8/1/19 at 8:49 AM revealed issues brought up in resident council were to be given to the SSD by the act… | 2020-09-01 |
| 714 | 714 | WORLAND HEALTHCARE AND REHABILITATION CENTER | 535048 | 1901 HOWELL AVENUE | WORLAND | WY | 82401 | 2019-08-01 | 582 | B | 0 | 1 | 07FS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the Notice to Medicare Provider Non-coverage (NOMNC) was issued to 1 of 3 sample residents (#264) reviewed. The findings were: Review of the medical record showed resident #264 had a planned discharged on [DATE] and there was no evidence the NOMNC was provided and signed. Review of the discharge evaluation from a care conference on 3/25/19 at 13:30 showed the discharge date was set to occur on 3/28/19 at 9:30 AM. Interview with MDS coordinator on 7/31/19 at 2:32 PM confirmed the NOMNC was not given. The MDS coordinator believed the notice was not required because the resident chose to discharge to the community. | 2020-09-01 |
| 715 | 715 | WORLAND HEALTHCARE AND REHABILITATION CENTER | 535048 | 1901 HOWELL AVENUE | WORLAND | WY | 82401 | 2019-08-01 | 585 | D | 0 | 1 | 07FS11 | Based on observation, resident and staff interview, medical record review, review of the facility grievance log, and policy review, the facility failed to ensure a process for grievance resolution for 2 of 5 sample residents (#14, #23) with reported grievances. The following concerns were identified: 1. Group interview with 9 residents, which included resident #14, on 7/30/19 at 11 AM revealed 2 of the 7 residents knew how to file a grievance and the group felt the facility did not always follow up with them after voicing concerns. Resident #14 indicated s/he had filed a grievance related to his/her toilet that took 2 months to fix and s/he had to talk to 3 different people before anything was completed. The following concerns were identified: a. Review of the grievance log showed no evidence of a grievance filed by resident #14. b. Interview with the administrator on 8/01/19 at 9:30 AM revealed she was aware of the resident's concern, and she stated the concern should have been filed as a grievance. c. Interview with the social services director on 8/01/19 at 8:25 AM revealed he did not recall any complaints of the toilet being broken. 2. Interview with resident #23 on 7/30/19 at 9:50 AM revealed the resident felt his/her room was dark and it made him/her feel closed in. Observation at that time showed the resident was sitting in a recliner with a closet on his/her right side and the bed on his/her left side. A curtain was pulled in the center of the room and the window blinds were closed. Interview with the resident on 7/31/19 at 4:08 PM revealed the resident had previously reported concerns about the room to a nurse and had spoken with the social services director about it 4 or 5 months ago. The following concerns were identified: a. Review of the grievance log showed no evidence of a grievance filed by resident #23. b. Interview with the social services director on 8/1/19 at 8:25 AM revealed he was not aware the resident had concerns with his/her room. 3. Interview with the social services director on 8/1/19 … | 2020-09-01 |
| 716 | 716 | WORLAND HEALTHCARE AND REHABILITATION CENTER | 535048 | 1901 HOWELL AVENUE | WORLAND | WY | 82401 | 2019-08-01 | 641 | D | 0 | 1 | 07FS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to ensure MDS assessments were accurate for 2 of 17 sample residents (#48, #62). The findings were: 1. Review of the medical record for resident #48 showed a preadmission screening and resident review (PASARR) was completed on 12/12/17 which indicated a referral for a PASARR level II. Further review showed the the PASARR Level II was completed on 12/28/17. Review of the 12/13/18 annual MDS assessment showed the resident had [DIAGNOSES REDACTED]. Further review showed section A1500 was coded as no, which indicated the resident had not been evaluated by level II PASARR and determined to have a serious mental illness and/or mental [MEDICAL CONDITION] or a related condition. Interview with the MDS coordinator on 7/31/19 at 11:23 AM revealed the facility had identified PASARR Level IIs that were completed had not been accurately coded for residents; however, there was not a performance improvement plan in place and she was updating them on comprehensive assessments as they were due. Further interview confirmed the resident's annual MDS assessment was not coded correctly. 2. Observation on 7/30/19 at 10:20 AM showed resident #62 had a bruise that was healing under his/her right eye. Review of the 7/10/19 at 2:40 PM interdisciplinary team note showed the resident had a fall on 7/7/19. The fall required the resident to be transferred to the emergency department, and the resident was then admitted to the hospital. Review of the radiology report dated 7/7/19 at 3:01 PM confirmed [MEDICATION NAME] compression fractures of an uncertain age. The following concerns were identified: a. Review of the 7/15/19 significant change MDS assessment showed the resident had 1 fall with non-major injury. b. Interview with the MDS coordinator on 7/31/19 at 2:46 PM confirmed a fall with major injury should have been coded. | 2020-09-01 |
| 717 | 717 | WORLAND HEALTHCARE AND REHABILITATION CENTER | 535048 | 1901 HOWELL AVENUE | WORLAND | WY | 82401 | 2019-08-01 | 755 | D | 0 | 1 | 07FS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy and procedure review the facility failed to ensure medications available for use were not expired in 1 of 3 medication storage units (hall 3-4 medication storage room). The findings were: 1. Observation on 7/31/19 at 3:23 PM showed the hall 3-4 medication storage room refrigerator had 3 [MEDICATION NAME] hcl (anti-[MEDICATION NAME], sedative, anti-nausea) 25 mg suppositories available for use that expired 6/2019. Continued review showed 10 [MEDICATION NAME] acetate (corticosteroid) 25 mg suppositories that had expired 6/2019. Interview at that time with RN #1 confirmed the medications were available for resident use and were expired. 2. Interview on 7/31/19 at 3:32 PM with DON revealed it was the facility expectation for nurse staff to remove expired medications from use when the medication had expired. 3. Review of the policy and procedure LTC (long term care) Facility's Pharmacy Services and Procedures Manual last revised 7/23/19 showed .17. Facility should destroy or return all discontinued, outdated/expired, or deteriorated medication . | 2020-09-01 |
| 718 | 718 | WORLAND HEALTHCARE AND REHABILITATION CENTER | 535048 | 1901 HOWELL AVENUE | WORLAND | WY | 82401 | 2019-08-01 | 803 | D | 0 | 1 | 07FS11 | Based on observation and staff interview, the facility failed to follow the menu related to portion sizes for 1 of 1 meal service observation (noon meal on 7/31/19). The findings were: Observation of the noon meal service in the secure unit on 7/31/19 at 11:41 AM showed CNA #1 was serving the food. When resident #33 was served s/he received 1 baked chicken leg and the side dishes. The following concerns were identified: a. Interview with CNA #1 at that time revealed she was uncertain what the serving size was for the pieces of chicken. On 7/31/19 at 11:56 AM the staff called to the kitchen and it was verified the serving size for the chicken was 2 pieces if a leg/wing/thigh or 1 breast piece. b. Continued observation showed resident #33 was not offered the second piece of chicken. c. Interview with CNA #1 on 7/31/19 at 12:09 PM revealed she had wanted to serve the remainder of the residents first, and by then the resident had left the table. d. Review of the resident's menu card showed a regular diet with no portion size modifications. The card showed 3 oz of Citrus Chicken Breast was the planned item and portion size. e. Interview with the CDM on 7/31/19 at 2:05 PM stated they don't always use the product that is on the sheet, and more education related to portion size and communication for those serving in the unit was needed. | 2020-09-01 |
| 719 | 719 | WORLAND HEALTHCARE AND REHABILITATION CENTER | 535048 | 1901 HOWELL AVENUE | WORLAND | WY | 82401 | 2019-08-01 | 812 | D | 0 | 1 | 07FS11 | Based on observation, staff interview, review of food temperature logs, and review of the U.S. Public Health Service Food Code, the facility failed to ensure pureed foods were held at an appropriate temperature for 9 of 31 days reviewed. In addition, the hood vents in the kitchen were in need of cleaning. The findings were: Review of the hall 4 daily food temperature sheets for (MONTH) 2019 showed there were 9 days when pureed foods were recorded below the hot holding temperature of 135 degrees Fahrenheit (F). The following concerns were identified: a. On 7/5/19 the pureed lunch vegetables were recorded as 54 degrees F. b. On 7/12/19 the pureed breakfast meat was recorded as 126 degrees F, and the pureed breakfast eggs were recorded as 130 degrees F. c. On 7/13/19 the pureed breakfast meat was recorded as 128 degrees F and the pureed lunch vegetable as 61 degrees F. d. 7/14/19 showed the pureed egg was recorded as 131 degrees F and the pureed lunch vegetable as 123 degrees F. e. 7/15/19 showed the pureed lunch starch was recorded as 127 degrees F. f. On 7/19/19 the pureed lunch meat was recorded as 130 degrees F and the pureed vegetable as 125 degrees F. g. On 7/22/19 the pureed breakfast meat was recorded as 124 degrees F, the egg as 123 degrees F and the pureed lunch meat as 110 degrees F. h. 7/27/19 showed the pureed breakfast egg was recorded as 130 degrees F, and the pureed lunch meat as 119 degrees F and the pureed starch as 134 degrees F. i. On 7/28/19 the pureed breakfast meat was recorded as 130 degrees F. 2. Observation on 7/29/19 at 4:28 PM and on 7/31/19 at 11:06 AM showed the removable hood vents above the range were in need of cleaning. There was a dark-colored accumulation of grease and dust visible in the vents. 3. Interview with the CDM on 7/31/19 at 2:05 PM verified the vents were on the cleaning schedule for every 2 weeks and they may be in need of more frequent cleaning. Further, the manager stated the food temperatures sheets showed there was education required on the appropriate food holding… | 2020-09-01 |
| 3265 | 3265 | KINDRED NURSING AND REHABILITATION - WIND RIVER | 535031 | 1002 FOREST DRIVE | RIVERTON | WY | 82501 | 2011-04-14 | 281 | D | 0 | 1 | 0F7J11 | Based on observation, staff interview, and medical record review, the facility failed to ensure physician's orders were followed for 1 non-sample resident (#48) during 1 of 2 medication pass observations. The findings were: According to the Wyoming Nurse Practice Act, revised July 2010, Section 3, pages 3-8 of the Wyoming State Board of Nursing's Administrative Rules and Regulations, nursing staff must function under the direction of a licensed physician. Refer to Federal citation F309 for details regarding RN #1 not following physician's orders regarding the administration of blood pressure medications to resident #48 | 2014-10-01 |
| 3266 | 3266 | KINDRED NURSING AND REHABILITATION - WIND RIVER | 535031 | 1002 FOREST DRIVE | RIVERTON | WY | 82501 | 2011-04-14 | 309 | D | 0 | 1 | 0F7J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and medical record review, the facility failed to ensure staff appropriately assessed the vital signs for 1 non-sample resident (#48) prior to administering anti-hypertensive medications. The findings were: Review of the April 2011 physician's recapitulation of orders for non-sample resident #48 showed the resident had [DIAGNOSES REDACTED]. Further review of this document showed a 4/28/09 order for [MEDICATION NAME] 25 milligram (mg) and [MEDICATION NAME] 10 mg (both used to treat high blood pressure) daily. In addition, the physician established the following parameters for both medications: [REDACTED]. The following concerns were identified: a. Observation on 4/13/11 at 11:40 AM showed RN #1 administered both [MEDICATION NAME] and [MEDICATION NAME] to the resident without first measuring his/her B/P or taking a pulse. Interview with the RN on 4/13/11 at 12:22 PM revealed she did not take vital signs prior to passing medications, rather she checked the vital signs clipboard. However, review of the vital signs clipboard showed the resident had not had any vital signs taken on that day. Furthermore, the resident was not on the list to have vital signs taken on a regular basis. b. Review of the March 2011 and April 2011 MARs showed no evidence staff checked the resident's B/P or pulse prior to administration of these medications which were administered daily. c. Review of the vital sign flow sheet history showed the resident's B/P and pulse were measured once on 3/17/11 and the diastolic reading was 58 (less than 60 as required). Both B/P medications were administered anyway. Review of the April 2011 vital sign flow sheet showed no B/P or pulse readings were recorded as measured as of 4/12/11. | 2014-10-01 |
| 3267 | 3267 | KINDRED NURSING AND REHABILITATION - WIND RIVER | 535031 | 1002 FOREST DRIVE | RIVERTON | WY | 82501 | 2011-04-14 | 371 | F | 0 | 1 | 0F7J11 | Based on observation, staff interview and review of the cleaning schedule, the facility failed to ensure food storage carts and the kitchen ventilation hood were maintained in a sanitary manner. The findings were: 1. Observation on 4/11/11 at 3:20 PM and on 4/12/11 at 4:45 PM showed the baffles in the hood system located above the range had a visible accumulation of grease. Interview with the corporate RD on 4/13/11 at 10:50 AM revealed the hood system was cleaned every six months by an outside service. Review of the April 2011 cleaning schedule showed the hood system was last cleaned on 4/10/11. However, based on observation this may have been inaccurate. During the interview the RD verified that the baffles were greasy and needed to be cleaned more frequently. According to Food Code 2009, U.S. Public Health Service: 4-601.11 "... (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris." 2. Observation on 4/11/11 at 3:20 PM and on 4/12/11 at 5:25 PM, revealed the four carts used to store and transport food trays to the resident dining areas were not clean. The interior of the carts had spilled food and splatters of food on the sides and the floor of the carts. On 4/12/11 at 5:25 PM observation showed the small cart that remained uncleaned was loaded with resident food trays for the evening meal. At that time, the dietary manager revealed they were to be cleaned daily according to the cleaning schedule. Review of the cleaning schedule for April 2011 showed the food carts were not cleaned on 4/10/11 or 4/11/11. According to Food Code 2009, U.S. Public Health Service: 4-601.11 "... (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris." | 2014-10-01 |
| 3268 | 3268 | KINDRED NURSING AND REHABILITATION - WIND RIVER | 535031 | 1002 FOREST DRIVE | RIVERTON | WY | 82501 | 2011-04-14 | 425 | D | 0 | 1 | 0F7J11 | Based on observation and staff interview, the facility failed to ensure medications were dated when they were opened and used prior to expiration on 1 of 1 medication carts (front hall). The findings were: Observation on 4/14/11 at 8:40 AM of the medication cart on the front hall showed the following medications were available for administration: a. Novalin R, a stock insulin, had been on opened 3/10/11 and was past the thirty day expiration window. b. Novolog Insulin for sample resident #4 had been opened on 3/5/11, which was past the thirty day expiration window. c. Lantus Insulin for sample resident #4 was undated as to when it was opened so the expiration window was unknown. d. Interview with the DON on 4/14/11 at 8:40 AM confirmed all the above medications should have been discarded. | 2014-10-01 |
| 3269 | 3269 | KINDRED NURSING AND REHABILITATION - WIND RIVER | 535031 | 1002 FOREST DRIVE | RIVERTON | WY | 82501 | 2011-04-14 | 428 | D | 0 | 1 | 0F7J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure irregularities identified during the pharmacist's monthly medication review were acted upon by the physician for 1 of 13 sample residents (#39). The findings were: Review of the 1/6/11 physician's orders [REDACTED]. [REDACTED]. Review of the physician's orders [REDACTED]. Interview with the DON on 4/14/11 at 10:50 AM confirmed there was no written response to the pharmacist's recommendation by the physician. | 2014-10-01 |
| 3270 | 3270 | KINDRED NURSING AND REHABILITATION - WIND RIVER | 535031 | 1002 FOREST DRIVE | RIVERTON | WY | 82501 | 2011-04-14 | 441 | E | 0 | 1 | 0F7J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure staff complied with recognized guidelines for hand-hygiene while preparing and administering medications during 1 of 2 medication pass observations. The findings were: The following concerns were identified during observation of the medication pass on 4/13/11 from 11:20 AM through 11:58 AM: a. RN #1 used hand sanitizer on her hands then touched the drawer handles, bubble packs, medication bottles, MARs, the top of the medication cart, and touched her pen prior to placing pills in the medication cup with her bare hands. The RN punched the pills out of the bubble packs into her bare hands or poured the pills out of a bottle into her bare hands then placed the pills into a medication cup for administration. This process occurred for 4 non-sample residents #46, #48, #50, and #52 with a total number of pills touched being 34. According to Elkin, Perry, & Potter in "Nursing Interventions and Clinical Skills," Fourth Edition, 2004, page 374: "Use good hand-hygiene technique for [MEDICATION NAME] medications. Avoid touching tablets and capsules." b. RN (#1) did not cleanse her hands at all between non-sample residents #48 and #50. c. Interview with RN #1 on 4/13/11 at 11:58 AM revealed she always used her bare hands to place medications in the pill cup. She further stated she was unaware using her bare hands to prepare medications was not appropriate. d. Observation on 4/13/11 at 11:58 AM showed RN #1 used her fingernail to remove the coating on a [MEDICATION NAME] tablet for non-sample resident #52. Interview at the time revealed she removed the coating because it had to be crushed and the resident did not like the flecks of coating. The RN did not cleanse or sanitize her hands before or after removing the coating with her fingernail, nor did she wear gloves. | 2014-10-01 |
| 3271 | 3271 | KINDRED NURSING AND REHABILITATION - WIND RIVER | 535031 | 1002 FOREST DRIVE | RIVERTON | WY | 82501 | 2011-04-14 | 467 | D | 0 | 1 | 0F7J11 | Based on observation and staff interview, the facility failed to provide outside ventilation in 3 of 3 interior resident bathrooms and 2 of 2 public restrooms on the front unit. The findings were: During the facility tour on 4/13/11 between 11:30 AM and 2:10 PM, observations showed the bathrooms in resident rooms 16, 26 and 29 as well as the men and women's public restrooms across from the front nurse's station did not have operating ceiling air vent fans. All restrooms were in the front hallway and all were interior rooms and, therefore, lacked exterior windows. Interview with the maintenance manager on 4/13/11 at 1:48 PM revealed he did not know why the ventilation system did not work, but he suspected "a telephone maintenance man must have caused a short in the ventilation system while recently working in the attic." | 2014-10-01 |
| 2424 | 2424 | GRANITE REHABILITATION AND WELLNESS | 535013 | 3128 BOXELDER DRIVE | CHEYENNE | WY | 82001 | 2013-07-23 | 252 | E | 1 | 0 | 0HSW11 | Based on observation and staff interview, the facility failed to provide residents a homelike environment by ensuring offensive odors to include urine were controlled or eliminated from the resident areas. The findings were: During random observations on 7/22/13 through 7/23/13 showed several resident areas had unpleasant odors noted. Resident rooms 111 and 117 located on the first floor were unoccupied with the bathroom doors closed. The bathrooms had a stale and unpleasant odor noted when the doors were opened. The vents were checked to determine if they pulled air from the room. A tissue was placed against the vent and it did not pull into the vent. Resident bathrooms in rooms 214 and 225 located on the second floor had odors of urine noted. The vents were checked and they did not show to be pulling air from the rooms. Resident room 208 had a strong odor of urine. Resident room 321 showed the bathroom had the smell of urine. The vent in the bathroom was checked and it did not pull the tissue into itself. The bathrooms observed with odors did not have windows. In addition, an observation on 7/23/13 at 8:15 AM showed the shower room across from the nurses' station was unoccupied and smelled of stool. During an interview with the maintenance manager on 7/22/13 at 3 PM, he stated he was aware the ventilation system was not working effectively. In addition, he acknowledged the vents located in resident bathrooms were pulling little to no air from the rooms. An interview with the DON on 7/22/13 at 3:30 PM verified there were unpleasant odors noted in the facility. | 2016-07-01 |
| 2602 | 2602 | GRANITE REHABILITATION AND WELLNESS | 535013 | 3128 BOXELDER DRIVE | CHEYENNE | WY | 82001 | 2013-02-21 | 309 | E | 1 | 0 | 0IF411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of policy and procedure, the facility failed to ensure all necessary assessments and monitoring were implemented for pain management for 3 of 5 sample residents (#15, #19, #114). The findngs were: 1. Review of the medical record for resident #114 showed s/he had [DIAGNOSES REDACTED]. Review of the admitting care plan dated 11/17/12 showed the resident was at risk for increased pain secondary to a recent left humerus fracture and decreased mobility. Review of the 11/10/12 physician orders [REDACTED]. (milligrams), two tablets po every 4 hours as needed for pain. During an interview with the 3rd floor nurse manager on 2/19/13 she stated that facility practice was to rate the pain level every shift with 0 to 10 scale for verbal rating or + (positive) or - (negative) for non-verbal expression on the MAR (medication administration record). The following concerns with pain management were identified: a. For the month of November, 2012 the resident was not assessed for pain for 13 out of a possible 63 shifts. Review of the November 2012 MAR and pain monitoring flowsheet showed [MEDICATION NAME] 5/325 was administered but not assessed for effectiveness on 11/11/12, 11/16/12. 11/22/12, and 11/24/12. Further review showed the [MEDICATION NAME] 5/325 was not documented as administered on the MAR, yet was assessed for effectiveness on the pain monitoring flow sheet on 11/19/12 and 11/20/12. b. Review of the 12/3/12 physician orders [REDACTED]. Review of the December MAR and the pain monitoring flowsheet, showed the effectiveness of the Tylenol was not assessed on 12/2/12. 2. Review of the medical record for resident #15 showed s/he had [DIAGNOSES REDACTED]. Review of the 11/6/12 admission physician orders [REDACTED]., 2 tablets po every 4 hours as needed for pain. The following concerns with pain management were identified: a. Review of the November 2012 MAR and pain monitoring flowsheet showed … | 2016-02-01 |
| 2603 | 2603 | GRANITE REHABILITATION AND WELLNESS | 535013 | 3128 BOXELDER DRIVE | CHEYENNE | WY | 82001 | 2013-02-21 | 323 | E | 1 | 0 | 0IF411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure 1 of 4 sample residents (#115) who was at risk for falls received an accurate post fall assessment. The findings were: Review of the admission nursing evaluation for resident #115 showed the resident was admitted to the facility on [DATE]. This review also revealed the resident was alert and oriented, ambulated with a cane, had a history of [REDACTED]. Review of the documentation written by RN #1, dated 2/1/13 at 1 AM, showed the resident was found lying face down on the floor by the sink. At that time the resident complained of left ankle pain when staff moved him/her from the floor to the bed. The resident also complained of pain when staff touched his/her ankle. According to the 1/25/13 documentation, RN #1 completed a neurological assessment at 1:20 AM, 1:35 AM, 1:50 AM, 2:20 AM. 3:20 AM, 3:50 AM, 4:50 AM and 5:50 AM. Review of each timed assessment showed the resident moved both lower extremities without difficulty and no changes in condition were noted. Review of the January 2013 medication administration record showed RN #1 assessed the resident's pain as zero from 1/31/13 at 10 AM to 2/1/13 at 6 AM. However, the RN had documented the resident said his/her ankle was sore at 5:15 AM and there were no orders for pain med (medication). Review of the 2/1/13 documentation by licensed practical nurse (LPN) #1 at 7:40 AM and RN #2 at 8 AM revealed their assessments of the resident's pain and injury were not the same as documented by RN#1. Review of the nursing note completed by LPN #2 showed she assessed the resident at 7:40 AM and noted the resident's ankle was swollen and bruised and there was increased pain with movement and touch. Review of the assessment completed by RN #2 showed she assessed the resident at 8 AM and the resident complained of left ankle pain. This review also showed the resident's ankle was swollen, purple and lying laterally on a pillow w… | 2016-02-01 |
| 2048 | 2048 | DOUGLAS CARE CENTER LLC | 535040 | 1108 BIRCH STREET | DOUGLAS | WY | 82633 | 2014-08-07 | 167 | B | 0 | 1 | 0IJ311 | Based on observation and staff interview, the facility failed to post the results of the most recent State survey in an area readily accessible to residents. The census was 58. The findings were: Observation on 8/7/14 at 10 AM revealed State survey results were posted in the foyer of the facility. However, there was a locked door between the resident living areas and the survey results. In order to access the results, residents had to ask a staff member to unlock the door. Interview with the DON on 8/7/14 at 11 AM confirmed the survey results were not available to residents without the intervention of staff. | 2017-08-01 |
| 2049 | 2049 | DOUGLAS CARE CENTER LLC | 535040 | 1108 BIRCH STREET | DOUGLAS | WY | 82633 | 2014-08-07 | 278 | D | 0 | 1 | 0IJ311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to ensure the MDS assessment was accurate for 3 of 15 sample residents (#16, #33, #39). The findings were: 1. Review of physician orders [REDACTED].#33 was ordered a Merry Walker (enclosed wheeled walker with a seat). Review of a 4/25/14 assessment for the use of the Merry Walker showed the instructions stated the Merry Walker would be considered a restraint if the resident was unable to open the gate independently. Observation on 8/6/14 at 4:25 PM showed the resident was in the Merry Walker. At 4:40 PM CNA #1 opened the gate to the Merry Walker and assisted the resident to transfer to a dining room chair. Interview with the CNA at that time revealed the resident had the ability to get out of a regular chair, but may fall. Review of the 8/4/14 quarterly MDS assessment showed the resident did not utilize any restraints. During an interview on 8/7/14 at 10:30 AM, the MDS coordinator confirmed the resident was unable to open the gate to the Merry Walker. She stated she did not code the Merry Walker as a restraint because she felt the device was the least restrictive for the resident. According to the Long-Term Care Facility Resident Assessment Instrument User's Manual, MDS 3.0, April 2012, .Enclosed-frame wheeled walkers, with or without a posterior seat, or other devices like it should not automatically be classified as a restraint. These types of walkers are only classified as a restraint if the resident cannot exit the gate. 2. Review of the 7/4/14 Braden scale (assessment to measure risk of development of pressure ulcers) showed resident #16 was at moderate risk for the development of pressure ulcers. However, review of the 7/4/14 annual MDS assessment showed the resident was coded as not being at risk for the development of pressure ulcers. During an interview on 8/7/14 at 10:30 AM the MDS coordinator confirmed the MDS assessment was not accurate in regards… | 2017-08-01 |
| 2050 | 2050 | DOUGLAS CARE CENTER LLC | 535040 | 1108 BIRCH STREET | DOUGLAS | WY | 82633 | 2014-08-07 | 279 | E | 1 | 1 | 0IJ311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to utilize the care planning process to address all of the identified problems for 4 of 15 sample residents (#5, #27, #29, #39). The findings were: 1. Review of the 7/8/14 significant change MDS assessment showed resident #39 triggered for further assessment in areas including [MEDICAL CONDITION], ADL functional/rehabilitation potential, nutritional status, pressure ulcers, and [MEDICAL CONDITION] drug use. Review of nurse charting dated 7/4/14 timed at 10:04 PM, showed the resident had an open area to the coccyx. Review of nurse charting dated 7/7/14, timed at 9:53 AM, showed the resident was weak, but able to go to the bathroom with staff assistance and using a walker. Review of section V of the same MDS assessment revealed the facility decided to proceed with care planning for these areas. However, review of the resident's care plan, last reviewed in its entirety on 7/23/14 at an interdisciplinary care conference, showed none of these areas were addressed in the care plan. 2. Review of the 11/29/13 annual MDS assessment showed resident #5 triggered for further assessment in ADL functional/rehabilitation potential. Review of section V of the same MDS assessment revealed the facility decision to proceed with care planning for this area. Comparison with the 5/18/14 quarterly MDS assessment showed the resident had experienced a decline in ADL self-performance in bed mobility, off unit locomotion, dressing, personal hygiene and bathing. However, review of the resident's care plan, last reviewed in its entirety on 5/21/14 at an interdisciplinary care plan conference, showed this care area was not addressed in the care plan. 3. Review of the 7/15/14 annual MDS assessment for resident #27 revealed care area assessments were triggered for the following: nutritional status and communication. Review of the resident's care plan showed these 2 areas were not addressed. 4. Review of… | 2017-08-01 |
| 2051 | 2051 | DOUGLAS CARE CENTER LLC | 535040 | 1108 BIRCH STREET | DOUGLAS | WY | 82633 | 2014-08-07 | 282 | D | 0 | 1 | 0IJ311 | Based on observation, staff interview and medical record review, the facility failed to ensure the care plan was followed for 1 of 13 sample residents (#9). The findings were: Review of the 12/4/13 significant change and the 5/23/14 quarterly MDS assessments showed resident #9 was coded as having highly impaired hearing. Review of the care plan, last updated on 3/3/14, showed one of the interventions to improve communication for this resident was to utilize a communication board. However, observation on 8/4/14 from 3 PM until 5:34 PM revealed the communication board was not used by the resident or staff. Observation from 8:30 AM to 11:23 AM on 8/5/14 also showed the resident did not utilize the communication board and was not encouraged to by staff. Further periodic observations on 8/6/14 and 8/7/14 revealed the communication board was not used by the resident or staff. Interview with the DON and staff development coordinator (SDC) on 8/7/14 at 9 AM revealed the communication board was kept in a drawer in the resident's room but should be more readily accessible for staff and others to use. Both the DON and SDC stated the communication board should be used as indicated on the care plan. | 2017-08-01 |
| 2052 | 2052 | DOUGLAS CARE CENTER LLC | 535040 | 1108 BIRCH STREET | DOUGLAS | WY | 82633 | 2014-08-07 | 313 | D | 0 | 1 | 0IJ311 | Based on observation, staff interview, and medical record review, the facility failed to ensure a communication board was accessible for 1 of 1 sample residents (#9) with impaired hearing and communication. The findings were: Review of the 12/4/13 significant change and the 5/23/14 quarterly MDS assessments showed resident #9 was coded as having highly impaired hearing. Review of the care plan, last updated on 3/3/14, showed one of the interventions to improve communication for this resident was to utilize a communication board. However, observation on 8/4/14 from 3 PM until 5:34 PM revealed the communication board was not used. Observation from 8:30 AM to 11:23 AM on 8/5/14 also showed the resident did not utilize the communication board at any time. Further periodic observations on 8/6/14 and 8/7/14 revealed the communication board was not used by the resident or staff. Interview with the DON and staff development coordinator (SDC) on 8/7/14 at 9 AM revealed the communication board was kept in a drawer in the resident's room but should be more readily accessible for staff and others to use. Both the DON and SDC stated the communication board should be used because the resident often became uncooperative and combative when s/he did not hear what staff wanted him/her to do. They felt it might decrease the resident's behaviors if s/he knew what was happening. | 2017-08-01 |
| 2053 | 2053 | DOUGLAS CARE CENTER LLC | 535040 | 1108 BIRCH STREET | DOUGLAS | WY | 82633 | 2014-08-07 | 332 | D | 1 | 1 | 0IJ311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to maintain a medication error rate of less than 5 percent (%). Two medication errors were observed out of 33 opportunities for error, which resulted in an error rate of 6.06%. Residents affected by these errors were 2 non-sample residents (#46, #56). The findings were: 1. Observation on 8/6/14 at 9:30 AM showed RN #1 gave resident #56 two tablets of calcium/magnesium/vitamin D 500/250/500 mg. Review of the 7/27/14 physician orders [REDACTED]. The 2 tablets that were administered was twice the amount ordered. 2. Observation on 8/7/14 at 9 AM showed RN #1 gave resident #46 Potassium liquid 15 ml (20 mEq) in apple juice. Review of the physician orders [REDACTED]. The resident was administered twice the amount of the medication as ordered. 3. Interview with the DON on 8/7/14 at 11 AM confirmed these medications were not given as ordered by the physician. | 2017-08-01 |
| 2054 | 2054 | DOUGLAS CARE CENTER LLC | 535040 | 1108 BIRCH STREET | DOUGLAS | WY | 82633 | 2014-08-07 | 356 | B | 0 | 1 | 0IJ311 | Based on observation and staff interview, the facility failed to post the total number of nursing staff and their actual hours worked in an area readily accessible to residents. The findings were: Observation on 8/4/14 at 4 PM revealed the nurse staffing and actual hours were posted in the entryway of the facility. However, there was a locked door between the resident living areas and the posting. In order to access the information, residents had to ask a staff member to unlock the door. In addition, the staffing was posted for the entire day instead of at the beginning of each shift as required. Observation on 8/7/14 at 8 AM revealed the posting remained in the same location. Interview with the DON on 8/7/14 at 9 AM confirmed the nursing staff posting was posted for the entire day instead of at the beginning of each shift. She also verified the information was not readily accessible to residents without asking for staff assistance. | 2017-08-01 |
| 2055 | 2055 | DOUGLAS CARE CENTER LLC | 535040 | 1108 BIRCH STREET | DOUGLAS | WY | 82633 | 2014-08-07 | 371 | E | 0 | 1 | 0IJ311 | Based on observation and staff interview, the facility failed to ensure nutritional supplements were not expired in 3 of 3 refrigerators. The findings were: Review of instructions written on the cartons of Mighty Shakes (nutritional supplements) showed the product was good for 14 days after thawing. The following concerns were identified: 1. Observation during the initial tour on 8/4/14 from 3:15 PM until 3:31 PM revealed the following: a. 24 Mighty Shakes were partially thawed in the walk-in refrigerator in the kitchen. The shakes were not labeled with the thaw date. b. 6 thawed Mighty Shakes were in the mini-fridge in the nursing station. There lacked thaw dates. c. The mini-fridge in the secure care unit (SCU) contained 2 thawed Mighty Shakes without a thaw date. 2. Observation on 8/5/14 at 10:10 AM showed the SCU refrigerator contained 7 thawed Mighty Shakes without a thaw date. 3. On 8/6/14 at 10:50 AM observation revealed 2 thawed Mighty Shakes in the walk-in refrigerator. The cartons were not labeled with the thaw date. 4. Observation on 8/6/14 at 2:25 PM showed 5 Mighty Shakes in the nursing station refrigerator. The cartons were not labeled with the thaw date. 5. During an interview on 8/6/14 at 2:26 PM the dietary manager stated she was not aware that Mighty Shakes were only good for 14 days after thawing. She confirmed the facility did not label the cartons with a thaw date. | 2017-08-01 |
| 2056 | 2056 | DOUGLAS CARE CENTER LLC | 535040 | 1108 BIRCH STREET | DOUGLAS | WY | 82633 | 2014-08-07 | 386 | D | 0 | 1 | 0IJ311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the physician progress notes [REDACTED].#9). The findings were: Review of physician progress notes [REDACTED]. During an interview on 8/7/14 at 11:05 AM, the DON and LPN #1 stated the facility was aware there were problems with obtaining physician written progress notes in a timely manner. | 2017-08-01 |
| 2057 | 2057 | DOUGLAS CARE CENTER LLC | 535040 | 1108 BIRCH STREET | DOUGLAS | WY | 82633 | 2014-08-07 | 387 | E | 0 | 1 | 0IJ311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the resident was seen by a physician at least every 60 days for 5 of 13 sample residents (#8, #16, #27, #29, #38). The findings were: 1. Review of physician progress notes [REDACTED]. The next visit was on 5/29/14, 84 days later. The facility was asked to provide any additional evidence of physician visits, but none was provided. 2. Review of the medical record showed the last documented physician visit for resident #38 was on 5/13/14. When asked to provide additional documentation, the facility submitted a note dated 6/5/14 which indicated the power of attorney (POA) declined to have the resident evaluated for an acute condition (swelling of hand). However, there lacked evidence the POA had refused any routine physician visit. 3. Review of physician progress notes [REDACTED]. There lacked evidence of a physician visit since 5/13/14. When asked to provide evidence of other physician visits, the facility provided a record of physician visit dated 4/4/14 which indicated it was for the cardio clinic. The only note from the physician was no changes and to follow-up in 6 months. There lacked evidence the physician evaluated the total program of care, including all medications and treatments. 4. Review of physician progress notes [REDACTED]. The facility was asked to provide any additional evidence of physician visits, but none was provided. 5. Review of physician progress notes [REDACTED]. Additionally, it had been 82 days since the last visit on 5/13/14. The facility was asked to provide any additional evidence of physician visits, but none was provided. 6. During an interview on 8/7/14 at 11:05 AM, the DON and LPN #1 stated the facility was aware there were problems with physician visits and they were working to address the issue. | 2017-08-01 |
| 3249 | 3249 | PIONEER MANOR NURSING HOME | 535022 | 900 W 8TH ST | GILLETTE | WY | 82716 | 2011-05-12 | 272 | E | 0 | 1 | 0J0T11 | Based on medical record review and staff interview, the facility failed to ensure a qualified professional completed nutritional assessments in the area of nutrition for 5 of 10 sample residents (#5, #17, #21, #78, #107). The findings were: 1. Review of the 12/22/10 quarterly MDS assessment for resident #5 showed s/he needed further assessment in the area of nutrition. Review of the 12/22/10 CAA for nutrition showed the assessments were signed as completed by certified dietary manager (CDM) #2. 2. Review of the 2/2/11 annual MDS assessment for resident #107 revealed the area of nutritional status triggered, requiring a comprehensive assessment. Review of the 1/20/11 CAA for nutrition revealed it had been completed by CDM #2 instead of the RD. 3. Review of the 12/21/10 significant change MDS assessment for resident #17 showed nutritional status triggered, which required a comprehensive assessment. Review of the 12/9/10 CAA for nutrition revealed it had been completed by CDM #2 instead of the RD. 4. Review of the 3/9/11 quarterly MDS assessment for resident #78 showed s/he needed further assessment in the area of nutrition. Review of corresponding CAA revealed the assessment was completed by CDM #2. 5. Review of the 3/11/11 admission MDS assessment for resident #21 showed s/he needed further assessment in the area of nutrition. Review of the 3/20/11 CAA revealed the assessment was signed by CDM #2. 6. During an interview with the MDS coordinator on 5/12/11 at 8 AM, she confirmed that a CDM completed most CAAs for nutrition. According to the 2008 Standards of Practice for Registered Dietitians in Nutrition Care, published by the American Dietetic Association, Standard 1: Nutrition Assessment, The registered dietitian (RD) uses accurate and relevant data and information to identify nutrition-related problems. Rationale: Nutrition Assessment is the first of four steps of the Nutrition Care Process. Nutrition Assessment is a systematic process of obtaining, verifying, and interpreting data in order to make decisions ab… | 2014-10-01 |
| 3250 | 3250 | PIONEER MANOR NURSING HOME | 535022 | 900 W 8TH ST | GILLETTE | WY | 82716 | 2011-05-12 | 279 | E | 0 | 1 | 0J0T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview, medical record review, and review of facility policies, the facility failed to ensure an individualized care plan was developed in a variety of areas for 8 of 19 sample residents (#3, #17, #21, #32, #48, #78, #102, #107). The findings were: In regard to pain: 1. Review of the medical record for resident #102 showed s/he had [DIAGNOSES REDACTED]. Interview with the resident on 5/9/11 at 4:05 PM revealed the fractured ribs were very painful. Review of the care plan for pain showed it was not individualized to target the specific area of pain in the ribs, there were no measurable goals, and the care plan did not include resident preferences regarding pain management. Interview with the two unit managers on 5/12/11 at 9:15 AM revealed care plans should be individualized. 2. Review of the care plan dated 3/27/11 for resident #21 showed s/he complained of pain daily or almost daily related to incisional and phantom pain. The goal was for pain to be reduced to an acceptable level to allow participation in therapies and activities of daily living (ADLs). The approaches were as follows: assist with repositioning as needed, offer applications of heat and/or cold as needed, medication as ordered by physician and offer as needed (PRN) medication prior to therapy sessions. The care plan was not individualized related to "acceptable" pain level for the resident and lacked measurable objectives for pain control during rest and activity. 3. Review of the April and May 2011 pain flow sheets for resident #17 showed s/he experienced pain and received [MEDICATION NAME] (narcotic pain medication) 5/500 milligrams 64 times for back, leg, coccyx or generalized pain in April 2011 and 22 times from 5/1/11 through 5/12/11. Review of the care plan for pain showed interventions were "alternative approach to pain relief, pain medications as ordered, eliminate precipitating factors (no precipitating factors were identified) and educa… | 2014-10-01 |
| 3251 | 3251 | PIONEER MANOR NURSING HOME | 535022 | 900 W 8TH ST | GILLETTE | WY | 82716 | 2011-05-12 | 280 | D | 0 | 1 | 0J0T11 | Based on observation, staff interview, and medical record review, the facility failed to ensure the care plan was updated to reflect the current needs for 2 of 19 sample residents (#78, #107). The findings were: 1. Review of the 2/2/11 CAA for resident #107 showed s/he was to receive a meal of finger foods at noon. Review of the care plan, however, showed the use of finger foods was not included as part of the intervention for nutrition. Interview with the two unit managers on 5/12/11 at 9:15 AM revealed finger foods should have been included on the care plan as part of the nutritional care plan interventions. 2. Random observations on 5/9/11 of resident #78 showed s/he was in a wheelchair and did not walk. Review of the 3/9/11 quarterly MDS showed the resident did not walk at any time in his/her room or corridor during the 7-day observation period. His/her care plan showed the resident "...used a walker with assist for short distances." Interview with LPN #1 on 5/12/11 at 8:30 AM verified the resident was not able to walk. | 2014-10-01 |
| 3252 | 3252 | PIONEER MANOR NURSING HOME | 535022 | 900 W 8TH ST | GILLETTE | WY | 82716 | 2011-05-12 | 281 | D | 0 | 1 | 0J0T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of policies and procedures, the facility failed to follow professional standards for 1 sample resident (#71) regarding a required change of the resident's PICC line dressing. In addition, the facility failed to follow professional standards regarding oxygen administration for 1 of 6 sample residents (#71) who required oxygen. The findings were: 1. Refer to F328 regarding the facility's failure to change a required PICC line dressing for resident #71. 2. Refer to F328 regarding the facility's failure to obtain a physician's orders [REDACTED]. [REDACTED]. | 2014-10-01 |
| 3253 | 3253 | PIONEER MANOR NURSING HOME | 535022 | 900 W 8TH ST | GILLETTE | WY | 82716 | 2011-05-12 | 282 | D | 0 | 1 | 0J0T11 | Based on observation, staff interview and medical record review, the facility failed to follow the plan of care for 1 of 19 sample residents (#48). The findings were: Review of the 4/19/11 care plan showed resident #48 had interventions developed to address pain and associated behaviors. Refer to citation F309 for details on the facility's failure to follow the planned interventions for this resident's pain. | 2014-10-01 |
| 3254 | 3254 | PIONEER MANOR NURSING HOME | 535022 | 900 W 8TH ST | GILLETTE | WY | 82716 | 2011-05-12 | 312 | D | 0 | 1 | 0J0T11 | Based on observation, medical record review, and staff interview, the facility failed to provide adequate incontinence care for 1 of 3 sample residents (#78) who required such assistance. The findings were: Observation of resident #78 on 5/9/11 at 4:45 PM showed CNA #1 failed to cleanse the resident's anterior perineum after s/he was found to be incontinent of urine. Medical record review of the 3/9/11 quarterly MDS revealed the resident required extensive assistance with toilet use and personal hygiene. Interview with LPN #2 on 5/11/11 at 1:20 PM revealed all areas of the skin that have come in contact with urine was to be cleansed. | 2014-10-01 |
| 3255 | 3255 | PIONEER MANOR NURSING HOME | 535022 | 900 W 8TH ST | GILLETTE | WY | 82716 | 2011-05-12 | 323 | D | 0 | 1 | 0J0T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to identify and correct potential accident hazards on 1 of 4 resident units. The findings were: 1. A wall-mounted fire extinguisher cabinet was observed while touring the secure unit on [DATE]. The metal cabinet had exposed corners with rough metal creases along the bottom. Donning examination gloves and running a hand across the lower corners caused the glove material to snag and tear against the rough surfaces. 2. Observation in the secure unit on [DATE] at 5:10 PM showed three fans placed on the floor in the hallway leading from the dining room to resident rooms. The fans were positioned against the walls of the hallway with the electrical cords secured behind the wall-mounted hand rail. Non-sample resident #99 left the dining room at 5:25 PM and walked to his room; the resident walked with a cane and further steadied his/her gait by leaning against the wall and handrail with his/her right shoulder and arm. On two occasions the resident altered his/her course to avoid these floor fans and was observed to shuffle around the fans with a hesitant, unsteady gait. Interview with RN #1 on [DATE] at 10:37 AM confirmed floor fans were used to augment ventilation in the secure unit. She acknowledged residents might find the fans to be an obstacle, particularly residents who ambulated with the aide of a cane or walker. A second staff interview with CNA #2 reiterated that floor fans were frequently used in the secure unit to help ventilation. | 2014-10-01 |
| 3256 | 3256 | PIONEER MANOR NURSING HOME | 535022 | 900 W 8TH ST | GILLETTE | WY | 82716 | 2011-05-12 | 328 | D | 0 | 1 | 0J0T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of policies and procedures, the facility failed to change a PICC line dressing for 1 of 1 sample resident (#71) who had a PICC (peripherally inserted central catheter) line. In addition, the facility failed to obtain, clarify, and follow physician's orders [REDACTED].#71) who required oxygen. The findings were: The following concerns were noted regarding the PICC line for resident #71: Review of the medical record for resident #71 showed s/he had [DIAGNOSES REDACTED]. The review showed the resident had a PICC that had been in his/her right upper arm that had been placed during a recent hospital stay. The PICC line was used to administer intravenous antibiotics. Observation on 5/10/11 at 10:20 AM showed the PICC line dressing was dated as last being changed 24 days earlier (4/16/11). The surveyor notified RN #3 of the date on the dressing and she immediately changed it. During an interview with RN #3 immediately after the dressing change, she stated the dressing should be changed every seven days in accordance with the facility's policy. According to the policy titled, "Central Venous Catheter Dressing Changes," revised October 2010, staff should "Change transparent semi-permeable membrane (TSM) dressings at least every 7 days and PRN (when wet, soiled, or not intact)." According to Elkin, Perry, and Potter in "Nursing Interventions & Clinical Skills," 4th Edition 2007: "Provide insertion site care every .....7 days and PRN for transparent dressings." The following concerns regarding oxygen administration for resident #71 was noted: Review of the medical record for resident #71 showed s/he had [DIAGNOSES REDACTED]. Observation on 5/10/11 from 8:30 AM through 9:15 AM (45 minutes) showed the resident was in bed, and there was oxygen via nasal cannula running at 2 liters per minute. However, the oxygen tubing was noted to be beside the resident in bed and not being used by t… | 2014-10-01 |
| 3257 | 3257 | PIONEER MANOR NURSING HOME | 535022 | 900 W 8TH ST | GILLETTE | WY | 82716 | 2011-05-12 | 329 | D | 0 | 1 | 0J0T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the drug regimen was free of unnecessary drugs for 1 of 19 sample residents (#5). The findings were: Review of the medical record for resident #5 showed s/he had [DIAGNOSES REDACTED]. Review of the April 2011 recapitulation of physician's orders [REDACTED]. Review of the monthly consultant pharmacist medication regimen review and physician notification showed a 10/14/10 recommendation by the pharmacist to continue the duloxetine and discontinue the [MEDICATION NAME] by a tapering schedule so that the resident's serotonin load could be further reduced. The medical record also showed the facility failed to receive a response to the recommendation, and failed to obtain an explanation as to why both serotonin reuptake inhibitor medications were continued as originally ordered. Further review of the medical record showed the facility failed to attempt a gradual dose reduction of the quetiapine, or obtain an explanation for continuing the medication as ordered. During an interview with the facility's two unit managers on 5/10/11 at 5 PM, both managers stated that no gradual dose reductions had been attempted for any of the three medications, and no explanations were given for not following the 10/14/10 pharmacist recommendations. According to Lexi-Comp's Drug Reference Handbooks Drug Information Handbook for Nursing 2010, there is a "Potential for severe reaction when ([MEDICATION NAME]) used with ....serotonin [MEDICATION NAME] reuptake inhibitor: serotoni[DIAGNOSES REDACTED] (hyperthermia, muscular rigidity, mental status changes/agitation, autonomic instability) may occur." | 2014-10-01 |
| 3258 | 3258 | PIONEER MANOR NURSING HOME | 535022 | 900 W 8TH ST | GILLETTE | WY | 82716 | 2011-05-12 | 428 | D | 0 | 1 | 0J0T11 | Based on staff interview and medical record review, the facility failed to ensure drug regimen review recommendations were acted upon for 1 of 19 sample residents (#5) who received medications. The findings were: Refer to F329 for details regarding failure of the facility to ensure that a drug regimen review recommendation was acted upon for resident #5. | 2014-10-01 |
| 3259 | 3259 | PIONEER MANOR NURSING HOME | 535022 | 900 W 8TH ST | GILLETTE | WY | 82716 | 2011-05-12 | 441 | D | 0 | 1 | 0J0T11 | Based on observation, staff interview, and consideration of nationally-recognized infection control guidelines, the facility failed to provide an acceptable hand washing area on 1 of 4 resident units. The findings were: Observation on 5/09/11 at 4:20 PM showed a hand washing area located in a small alcove at the nurses station in the secure unit. The hand washing facility included a sink and wall-mounted soap and paper towel dispensers. Two sharps containers were also observed in the hand washing area; a large container was located immediately adjacent to the sink and directly in front of the soap dispenser, a smaller container was positioned beneath the paper towel dispenser. Sharps containers are hard plastic waste receptacles used for medical items that have a point, sharp edge, or tip that can puncture the skin and potentially create an infection hazard. Both containers in the hand washing area were about 1/3 filled with lancets, needles, blood collection tubes, plastic tubing, and other unidentified waste. Several of these items appeared to have been used to draw blood or collect finger-stick blood samples. On 5/10/11 at 1:35 PM, CNA #2 was observed at the hand washing sink. She slid the large sharps container away from the soap dispenser with her right hand on top of the container near the opening used to discard sharps. Once she washed and rinsed her hands, she pushed the sharps container back toward the soap dispenser and waved her hand in front of the paper towel dispenser to trigger the auto-dispense function. About 12 inches of paper towel was fed from the dispenser, the leading edge rolled across the top of the second sharps container and exposed 3 inches of paper towel to a potentially contaminated surface. The infection control nurse stated in interview on 5/11/11 at 11:50 AM sharps containers should not be at a hand washing station, particularly when they contained infectious materials. Observations on 5/11/11 at 1:50 PM revealed staff had removed the sharps containers from the hand washing station… | 2014-10-01 |
| 3260 | 3260 | PIONEER MANOR NURSING HOME | 535022 | 900 W 8TH ST | GILLETTE | WY | 82716 | 2011-05-12 | 503 | D | 0 | 1 | 0J0T11 | Based on observation, staff interview, and review of package inserts for laboratory supplies, the facility failed to comply with manufacturer's requirements for whole blood glucose testing at 2 of 3 testing locations. The findings were: On 5/11/11 and 5/12/11, the current lot numbers of glucose test strips and quality control materials on unit 2, 3, and 5 were inspected. The manufacturer's instructions for these supplies were reviewed on 5/12/11; the manufacturer stated in the package inserts that glucose test strips have a 180-day open vial expiration date. Similarly, the liquid quality control material was noted to expire 90 days after opening. Inspection of the vials containing test strips and quality control material failed to show that product expiration dates were modified as required by the manufacturer to reflect the open vial stability for testing supplies found on units 2 and 3. Further review of quality control log sheets on 5/12/11 failed to provide information on lot numbers and dates when new packages of supplies were opened, making it impossible to reconstruct a timeline for in-use dates of new lot numbers. Interview with RN #2 and CNA #2 revealed staff had not read the manufacturer's package insert and were not aware glucose testing supplies had an open vial stability date that reduced the products' potency period. They further acknowledged they did not remember when the current glucose test strips or quality control materials were first opened and placed into use. Title 42 of the Code of Federal Regulations, Part 493, Laboratory Requirements (aka Clinical Laboratory Improvement Amendment (CLIA)), requires that laboratory testing personnel follow the manufacturer's requirements for use, storage, and expiration. Further, reagents and supplies must be labeled with the correct expiration date and are not to be used past expiration. | 2014-10-01 |
| 3261 | 3261 | PIONEER MANOR NURSING HOME | 535022 | 900 W 8TH ST | GILLETTE | WY | 82716 | 2011-05-12 | 510 | D | 0 | 1 | 0J0T11 | Based on staff interview and medical record review, the facility failed to ensure an electrocardiogram (ECG) was performed every six months as ordered for 1 of 12 sample residents (#107)who had radiology tests ordered. The findings were: Review of the signed May 2011 physician's recapitulation of orders for resident #107 showed an order dated 12/8/08 for an electrocardiogrm (ECG) every six months. Review of the medical record, however, revealed no evidence an ECG had been performed in the past year. Interview with the two unit managers on 5/12/11 at 9:15 AM confirmed no ECG had been performed in the past year. | 2014-10-01 |
| 3262 | 3262 | PIONEER MANOR NURSING HOME | 535022 | 900 W 8TH ST | GILLETTE | WY | 82716 | 2011-05-12 | 514 | D | 0 | 1 | 0J0T11 | Based on medical record review and staff interview, the facility failed to assure the physician recapitulation of orders for May 2011 was accurate for 1 of 19 sample residents (#107). The findings were: Review of the physician's monthly orders for resident #107 showed the following orders which were most likely inaccurate, according to an interview with the two unit managers on 5/12/11 at 9:15 AM: a. There was a 1/27/10 order "Do not shave patient in future, may trim beard PRN." Observation on all days of the survey revealed the resident did not have a beard. b. There was a 5/6/09 order for "physical therapy five times per week for four weeks for debriedement and dressing change." However, observation and medical record review showed the resident had no wound. c. Interview with the two unit managers on 5/12/11 at 9:15 AM revealed the above noted orders were still current valid orders based on being signed by the physician on 5/4/11. Continued interview revealed the nurses were supposed to review all orders one week prior to the physician's visit to see if any clarifications were needed. | 2014-10-01 |
| 3263 | 3263 | PIONEER MANOR NURSING HOME | 535022 | 900 W 8TH ST | GILLETTE | WY | 82716 | 2011-05-12 | 309 | G | 0 | 1 | 0J0T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff and resident interview, the facility failed to ensure 2 of 10 sample residents (#21, #48) identified by the facility as having pain, had an effective pain management program. Due to the facility's failure in developing and implementing a pain management program, resident #48 experienced avoidable pain during staff assisted transfers. The findings were: In regard to pain concerns: 1. Review of the admission MDS assessment completed on 1/24/11 showed resident #48 had active [DIAGNOSES REDACTED]. Review of the psychologist's consultation dated 3/9/11 showed the resident exhibited behavioral problems including aggression during care. Further review of the consultation showed "...back pain should be targeted as a potential variable related to physical aggression." The evaluation showed that "Chart review and resident assessment reveal that (the resident) has a history of back injury and surgery...(the resident) reports that medication helps pain intensity somewhat and that, at home, (s/he) used heat and pressure to help manage (his/her) low back pain." Continued review of the consultation showed the psychologist made detailed recommendations that were discussed with the interdisciplinary team. These recommendations were to train staff to assess pain prior to transfer using a simple pain rating scale or a simple yes/no pain question. In addition, she recommended the charge nurse be familiar with the resident's problems with pain, and to "consult with family members, review the chart, and discuss the issue with (the) resident so that everyone was on the same page about (his/her) potential for significant pain." The recommendations also included the need for staff to be trained regarding non-medicinal options for pain control. Finally a recommendation to, "...consider requesting re-evaluation of current pain management medication for optimum effectiveness..." Review of the resident's medical reco… | 2014-10-01 |
| 156 | 156 | WESTON COUNTY HEALTH SERVICES | 535023 | 1124 WASHINGTON BLVD | NEWCASTLE | WY | 82701 | 2017-02-09 | 253 | E | 0 | 1 | 0JJ011 | Based on observation and staff interview, the facility failed to ensure 6 of 7 resident areas (100 hall, 200 hall, 300 hall, 400 hall, common area, activities room) were clean and in good repair. The findings were: 1. Concerns identified on the 100 hall: a. Observation on 2/7/17 at 10:05 AM showed 2 ceiling tiles outside of room #1 had a rectangle-shaped cover in the center of the tile that had water damage. b. Observation on 2/7/17 at 10:06 AM showed a 2-inch by 2-inch plaster repair on the wall between room #3 and #4 that could not be cleaned effectively. 2. Concerns identified on the 200 hall: a. Observation on 2/7/17 at 10:20 AM showed a crack in the wall, 12 inches in length, that ran down from the ceiling beam on the left side of the door frame of the shower room. b. Observation on 2/7/17 at 10:24 AM showed a 19-inch by 7-inch plaster patch in the wall by room #27 that could not be cleaned effectively. In addition, there was water damage to 3 ceiling tiles between room #27 and room #22. c. Observation on 2/7/17 at 10:25 AM outside of room #23 showed a 1-inch by 1/2-inch section of wall which was damaged and exposed the underlying material. Further, the wall outside of room #24 had 2 damaged areas which measured 1-inch by 1/4-inch, and 3/4-inch by 1/2-inch. The wall to the left of the door to room #25 had a damaged area measuring 2 inches by 1/2-inch that could not be cleaned effectively. 3. Concerns identified on the 300 hall: a. Observation on 2/9/17 at 9:45 AM showed a section of floor in room #9 had a 4-foot by 1/2-inch long seam under the foot of the bed that was not properly secured. A section of floor by the sink had a 41-inch by 14-inch rippled and torn area that could not be cleaned effectively. 4. Concerns identified on the 400 hall: a. Observation on 2/7/17 at 10:40 AM showed part of the push rail on the exit door by room #29 was missing a cover, which exposed the wiring and caused a safety hazard for the residents. 5. Concerns identified in the Common area: a. Observation on 2/7/17 at 10:10 AM sh… | 2020-09-01 |
| 157 | 157 | WESTON COUNTY HEALTH SERVICES | 535023 | 1124 WASHINGTON BLVD | NEWCASTLE | WY | 82701 | 2017-02-09 | 309 | G | 0 | 1 | 0JJ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, and policy and procedure review, the facility failed to promptly assess 1 of 6 sample residents (#51) who had a change of condition. This failure resulted in a delay in treatment and actual harm to the resident. In addition, the facility failed to perform neurological assessment for 1 of 6 sample residents (#16) with falls. The findings were: 1. Review of a Health Status Note dated 11/19/16 and timed 4:16 PM showed resident #51 was scheduled to go out with his/her family; however, the trip was canceled because the resident stated s/he did not .feel well enough to go . Further review of the medical record failed to show any evidence a nursing assessment was completed when the resident complained of feeling unwell. 2. Review of a Change of Condition late entry note dated 11/20/16 and timed 8 AM showed resident #51 was unresponsive when the nurse attempted to wake him/her up for breakfast. The resident was noted to have had complaints of an upset stomach the previous day. Further, the note indicated the change .Appeared to have started on: 11/19/16 . and the resident was transferred to the hospital on [DATE]. 3. Review of the ER Note dictated on 11/21/16 at 1:13 AM showed resident #51 was admitted on [DATE] and the family member stated the resident did not feel well yesterday and canceled a family outing that had been planned and reports that (s/he) was complaining of nausea and may have had some vomiting also . The note indicated the resident had not been seen since 7:30 PM on 11/19/16, 12 1/2 hours prior to being found unresponsive. During the physical examination the resident's blood glucose was determined to be less than 20 and 2 amps (ampoules) of D 50 ([MEDICATION NAME] 50%) was given. The resident's blood sugars improved; however, the resident remained unresponsive. Further, the physician was notified by the laboratory that the resident's lactic acid was elevated and the physician determine… | 2020-09-01 |
| 158 | 158 | WESTON COUNTY HEALTH SERVICES | 535023 | 1124 WASHINGTON BLVD | NEWCASTLE | WY | 82701 | 2017-02-09 | 323 | E | 0 | 1 | 0JJ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy and procedure review, the facility failed to ensure safety for 5 of 7 sample residents (#16, #34, #35, #37, #41) with positioning devices. The findings were: 1. Review of the 1/18/17 significant change MDS assessment showed resident #35 had [DIAGNOSES REDACTED]., and muscle weakness, and the resident had a BIMS (brief interview for mental status) score of 9 (moderately impaired). Further, the resident required the extensive assistance of 2 people for bed mobility and transfers and was not coded as having physical restraints while in bed. The following concerns were identified: a. Observation on 2/6/17 at 7:25 PM showed the resident had an enabler applied to one side of the bed and the other side of the bed was placed against the wall. b. Observation on 2/9/17 at 9 AM showed the enabler was designed to have a gap between the bars which was large enough for the the resident to place a limb through. The gaps measured 4 1/2 inches by 4 inches. c. Review of the resident's medical record showed no evidence that a safety assessment of the enabler was completed. 2. Review of the 1/25/17 annual MDS assessment showed resident #16 had [DIAGNOSES REDACTED]. The resident had a BIMS score of 13 (cognitively intact) and required the extensive assistance of 1 person for bed mobility and transfers. Further, the resident was not coded as having physical restraints in bed. The following concerns were identified: a. Observation on 2/6/17 at 7:15 PM showed the resident had an enabler applied to one side of the bed and the other side of the bed was placed against the wall. b. Observation on 2/9/17 at 9:15 AM showed the enabler was designed to have 2 gaps between the bars which were large enough for the resident to place a limb through. The top gap measure 4 inches by 6 inches and the bottom gap measured 4 inches by 4 inches. c. Review of the resident's medical record showed no evidence that a… | 2020-09-01 |
| 159 | 159 | WESTON COUNTY HEALTH SERVICES | 535023 | 1124 WASHINGTON BLVD | NEWCASTLE | WY | 82701 | 2017-02-09 | 371 | E | 0 | 1 | 0JJ011 | Based on observation and staff interview, the facility failed to ensure outdated food items were not available for resident consumption in 2 of 3 food storage areas (walk-in cooler #1, walk-in cooler #2). The findings were: 1. Observation of walk-in cooler #2 on 2/6/17 at 6:30 PM showed sliced cheese dated 1/23/17, a bottle labeled mayo dated 1/24/17, ketchup dated 1/24, a squirt bottle with yellow substance that was not labeled or dated, and sliced meat dated 1/19/17. All of the items had been removed from the original packaging. 2. Observation of walk-in cooler #2 on 2/8/17 at 3:05 PM showed sliced cheese dated 1/23/17 and sliced meat that was unlabeled dated 1/19/17. 3. Observation of walk-in cooler #1 on 2/8/16 at 3:15 PM showed five 2-ounce containers labeled honey mustard were not dated and had been removed from the original container. 4. Interview with the dietary manager on 2/8/17 at 3:10 PM revealed all items in the walk-in coolers should be labeled and discarded after 5 days. 5. According to Food Code 2013, U.S. Public Health Service: 3-501.17 (A) .refrigerated, READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. | 2020-09-01 |
| 160 | 160 | WESTON COUNTY HEALTH SERVICES | 535023 | 1124 WASHINGTON BLVD | NEWCASTLE | WY | 82701 | 2017-02-09 | 496 | B | 0 | 1 | 0JJ011 | Based on employee record review and staff interview, the facility failed to ensure employees met competency evaluation requirements for 2 of 2 employees (CNA #1, CNA #2) working at the facility. The findings were: 1. Review of the employee file for CNA #1 on 2/9/17 at 9 AM showed the CNA was hired on 11/15/16. Further review showed the CNA certification was not verified until 12/7/16 and the CNA abuse registry was not verified until 12/16/16. 2. Review of the employee file for CNA #2 on 2/9/17 at 9 AM showed the CNA was hired on 11/1/16. Further review showed the CNA certification was not verified until 12/7/16 and the CNA abuse registry was not verified until 12/7/16. The information to place the CNA on the registry was sent in to the State survey agency on 12/7/16 since the CNA had recently received her certification on 10/20/16. 3. Interview with the human resources coordinator on 2/9/17 at 9:12 AM revealed the facility usually checked licensure and the abuse registry before staff were hired; however, she did not have evidence the verification was done prior to employment or resident contact. | 2020-09-01 |
| 161 | 161 | WESTON COUNTY HEALTH SERVICES | 535023 | 1124 WASHINGTON BLVD | NEWCASTLE | WY | 82701 | 2017-02-09 | 499 | B | 0 | 1 | 0JJ011 | Based on employee record review and staff interview, the facility failed to ensure staff were licensed for 1 of 1 employees (LPN #1) in accordance with State law. The findings were: Review of the employee file for LPN #1 on 2/9/17 at 9:10 AM revealed the LPN was hired on 10/11/16. Further review showed the LPN's license was verified on 12/8/16. Interview with the human resource coordinator on 2/9/17 at 9:12 AM revealed the facility usually checked licensure before staff were hired; however, she did not have evidence the verification was done prior to employment or resident contact. | 2020-09-01 |
| 453 | 453 | WESTWARD HEIGHTS CARE CENTER | 535034 | 150 CARING WAY | LANDER | WY | 82520 | 2018-07-26 | 565 | D | 0 | 1 | 0JZF11 | Based on review of resident council meeting minutes and resident and staff interview, the facility failed to ensure grievances from the resident council were acted upon and followed through to resolution for 3 of 3 months reviewed (May (YEAR), (MONTH) (YEAR), (MONTH) (YEAR)). The findings were: 1. Review of the resident council meeting minutes for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) showed concerns were discussed related to call light response times. The following concerns were identified: a. Interview with 9 residents on 7/24/18 at 11 AM revealed there had been no response from the facility in regard to the grievance made about call lights in both (MONTH) (YEAR) and (MONTH) (YEAR). b. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) resident council minutes section Old Business showed no reference to the concern about call lights. c. Interview with the life enrichment coordinator on 7/24/18 at 2:26 PM revealed concerns brought up at council meetings were converted to individual resident grievances and then assigned to the appropriate department head. Further, she verified she did not discuss the resolution of the concerns with the resident council because she thought they were handled individually. | 2020-09-01 |
| 454 | 454 | WESTWARD HEIGHTS CARE CENTER | 535034 | 150 CARING WAY | LANDER | WY | 82520 | 2018-07-26 | 623 | E | 0 | 1 | 0JZF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure a transfer notice was issued to 5 of 5 sample residents with hospital transfers (#4, #34, #36, #43, #47). The findings were: 1. Review of the medical records showed resident #4 was transferred to the hospital on [DATE]. Further review showed no evidence the facility issued a written notice of transfer to the resident or the resident's representative. 2. Review of the medical record showed resident #34 was transferred to the hospital on [DATE] and 7/3/18 for acute changes of condition. In addition the resident was transferred to the hospital on [DATE] for a scheduled surgery. Further review showed no evidence the facility issued a written notice of transfer to the resident or the resident's representative. 3. Review of the medical record showed resident #36 went to the hospital due to a change in condition on 3/16/18 and returned on 3/19/18. Further review showed no evidence the facility issued a written notice of transfer to the resident or the resident's representative. 4. Review of the medical record showed resident #43 was transferred to the hospital on [DATE] for an acute change of condition. Further review showed no evidence the facility issued a written notice of transfer to the resident or the resident's representative 5. Review of the medical record showed resident #47 was transferred to the hospital via the facility van on 1/18/18 and 7/17/18 for an acute change of condition. On 5/31/18 the resident was transferred to urgent care for an acute change of condition and was then transferred to the hospital and admitted to the intensive care unit. Further review showed no evidence the facility issued a written notice of transfer to the resident or the resident's representative. 6. Interview on 7/25/18 at 10:03 AM with the DON and the administrator confirmed the facility did not issue a written notice of transfer with all required information to the resident o… | 2020-09-01 |
| 455 | 455 | WESTWARD HEIGHTS CARE CENTER | 535034 | 150 CARING WAY | LANDER | WY | 82520 | 2018-07-26 | 657 | D | 0 | 1 | 0JZF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and staff interview, the facility failed to ensure the care plan was revised as needed for 1 of 13 sample residents (#155). The findings were: 1. Review of a nurse's note dated 7/11/18 and timed 6:02 PM showed resident #155 was being transferred from urgent care to the hospital for septic shock to Right Upper Lobe. The resident was readmitted to the facility on [DATE]. The following concerns were identified: a. Review of a nurse's note dated 7/19/18 and timed 12:49 PM showed the resident has been observed to have difficulty swallowing and it was reported to this RN by occupational therapist that resident has been coughing when (s/he) drinks water . The physician was notified and an order was requested for the resident to have nectar thick liquids. b. Review of a physician communication form dated 7/19/18 showed Resident has been observed to have difficulty swallowing and has been coughing when (s/he) drinks water. We do not have in-house speech therapy until the end of next week. Could we have an order for [REDACTED]. The physician agreed with the request and the order was noted by the DON. c. Review of a Diet order and Communication form dated 7/19/18 showed the resident's diet had been changed to nectar-like thickened liquids. d. Review of the nutrition care plan revised on 7/25/18 (6 days after liquids had been downgraded) showed the resident was to have a regular diet, regular texture, and nectar thick liquid consistency. 2. Interview on 7/26/18 at 9:34 AM with the DON confirmed the care plan had not been revised until 7/25/18. | 2020-09-01 |
| 456 | 456 | WESTWARD HEIGHTS CARE CENTER | 535034 | 150 CARING WAY | LANDER | WY | 82520 | 2018-07-26 | 661 | D | 0 | 1 | 0JZF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a discharge summary which included a recapitulation of the resident's stay for 1 of 1 residents (#41) reviewed for discharge to the community. The findings were: Review of the medical record for resident #41 showed s/he was admitted to the facility on [DATE] for rehabilitation. The resident was discharged to the community on 7/13/18. Further review showed no evidence a recapitulation of the resident's stay had been completed. Interview on 7/26/18 at 9:05 AM with the DON verified the discharge summary was not complete. In addition, she stated the facility previously completed the summary on paper, but had converted to an electronic medical record system and in the process failed to carry-over the procedure. | 2020-09-01 |
| 457 | 457 | WESTWARD HEIGHTS CARE CENTER | 535034 | 150 CARING WAY | LANDER | WY | 82520 | 2018-07-26 | 689 | J | 0 | 1 | 0JZF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, product label and direction information review, and staff interview, the facility failed to implement a system to ensure thickened liquids were provided at the ordered consistency for 2 of 3 residents who received thickened liquids (#22, #155). Observations during the survey showed staff were not knowledgeable about the preparation of nectar-thickened liquids and provided these residents drinks that were too thin, increasing their risk for swallowing and potential aspiration problems. The record reviews for these residents showed they both had recent [DIAGNOSES REDACTED]. This resulted in an immediate jeopardy situation for these residents. The findings were: 1. Review of speech therapy notes showed resident #22 was evaluated on 6/5/17, 11/9/17, and 6/29/18. The notes from these evaluations showed the resident presents with a high risk of aspiration. Review of the 6/29/18 evaluation showed the reason for referral was choking during meal time, and according to the plan the resident would be seen twice weekly for a certification period from 6/29/18 to 9/20/18. Review of the care plan showed the resident had a problem dated 5/18/18 for Potential risk for infection related to dependence for cares, swallowing/aspiration risk . In addition, the care plan identified a problem on 6/19/17 related to Resident is at risk for dehydration r/t (related to) contractures in his hands, dementia, inability to retrieve fluids on his own along with current thickened liquids status. The 9/9/17 intervention for this problem included Thicken all liquids to nectar thick consistency .Ensure proper consistency of fluids at activities, etc .Offer fluids in wavy straw cups .Needs to sit upright for 30 mins (minutes) after meals. The following concerns were identified: a. Observation on 7/23/18 at 5:20 PM showed CNA #1 prepared thickened coffee for the resident by shaking thickening powder from a sugar shaker located on the be… | 2020-09-01 |
| 458 | 458 | WESTWARD HEIGHTS CARE CENTER | 535034 | 150 CARING WAY | LANDER | WY | 82520 | 2018-07-26 | 761 | D | 0 | 1 | 0JZF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy and procedure, the facility failed to ensure medications available for use were not expired in 1 of 2 medication carts (A hall cart). The finding were: 1. Observation on [DATE] at 4:57 PM of the A hall medication cart revealed 1 opened multiple-use vial of Humalog 100 unit/milliliter with no written open date. Further, observations revealed 1 open multiple-use vial of [MEDICATION NAME] 100 unit/milliliter with no written open date. 2. Observation on [DATE] at 11:03 AM of the A hall medication cart revealed 2 cards (a total of 111 tablets) of [MEDICATION NAME]-APAP ,[DATE] mg that expired on [DATE]. 3. Interview with RN #1 on [DATE] at 11:03 AM confirmed the medications were expired and still available for use. 4. Review of the policy titled, Medication storage and utilization, dated ,[DATE], showed .10. All multi-dose vials, bottles, and containers will be dated when opened. 11. Multi-dose vials which have been opened or accessed should be discarded within 28 days unless the manufacturer specifies a different date for that opened vial. | 2020-09-01 |
| 459 | 459 | WESTWARD HEIGHTS CARE CENTER | 535034 | 150 CARING WAY | LANDER | WY | 82520 | 2018-07-26 | 812 | F | 0 | 1 | 0JZF11 | Based on observation, staff interview, review of monitoring logs, review of maintenance records, and review of product labels, the facility failed to implement a system that ensured dietary staff were knowledgeable regarding the importance of taking action to correct inadequate final rinse temperatures of the dish-machine, and implementing alternatives to ensure resident dinnerware and utensils were effectively sanitized to minimize the potential for food-borne illness in 1 of 1 food preparation areas (kitchen). The census was 54. Further, the facility failed to ensure appropriate hand-hygiene techniques in 1 of 1 food preparation areas (kitchen), and failed to ensure proper dating and labeling of pre-thickened beverage products in 2 of 2 storage areas (resident room, beverage refrigerator in the dining room). The findings were: Regarding inadequate final rinse temperatures of the dish machine: 1. Review of the (MONTH) 1-23, (YEAR) dish-machine temperature log showed the hot water rinse temperature was recorded twice per day for the month with the exception of 7/3/18 and 7/22/18 when there were no temperatures recorded. Of the times when hot rinse temperatures were recorded, there were 27 temperatures that were shown to be less than 180 degrees Fahrenheit (F). There were no notes on the log to show corrective actions taken. Interview with the CDM on 7/23/18 at 3:09 PM revealed she was aware the rinse temperatures had been problematic since after the installation of the new booster heater. The CDM revealed the recorded temperatures were taken by looking at the temperature gauge located on the outside of the machine. The manager verified an internal temperature was not taken by using a temperature strip indicator or a holding thermometer. The manager also stated there were times when the maintenance director was contacted to fix the problem, and it would be okay for a few days. She further acknowledged the dish-machine continued to be used although the temperatures were not sufficient. 2. Review of the invoice for … | 2020-09-01 |
| 1090 | 1090 | CASPER MOUNTAIN REHABILITATION AND CARE CENTER | 535024 | 4305 S POPLAR | CASPER | WY | 82601 | 2016-12-15 | 157 | D | 1 | 0 | 0KN611 | > Based on staff interview, and medical record review, the facility failed to immediately notify the resident's family/representative for 1 of 2 incidents reviewed. The findings were: Review of the incident/accident report dated 12/2/16 at 2:02 AM showed resident #2 was the victim of a resident-to-resident physical abuse incident. The resident was sitting in his/her room when resident #6 came in and started hitting him/her with closed fist and ramming his/her lower legs with their walker. Review of the progress note dated 12/2/16 at 2:02 AM showed Resident is terrified of being attacked again. Review of the nursing note dated 12/2/16 at 3:16 PM showed, Multiple bruises noted to bilateral lower extremities (BLE) and bilateral upper extremities (BUE). Bruise noted to left temporal area, and around left eye. Skin tear noted to right shin. The following concerns were identified: a. Review of the progress report dated 12/2/16 timed at 2:02 AM showed the resident's son was notified of the incident on 12/2/16 at 2:00 PM, twelve hours after the incident which resulted in injury and fear for the resident. b. Interview with the DON on 12/15/16 at 11:00 AM revealed his expectation was for the family/representative to be notified of injury and change in condition as soon as possible. In addition, he confirmed the facility did not have a policy related to notifying family/representatives of incidents. | 2019-11-01 |
| 1091 | 1091 | CASPER MOUNTAIN REHABILITATION AND CARE CENTER | 535024 | 4305 S POPLAR | CASPER | WY | 82601 | 2016-12-15 | 225 | D | 1 | 0 | 0KN611 | > Based on staff interview, review of medical records and facility incident/accident reports, policy and procedure review, and review of State Survey Agency records, the facility failed to ensure 2 of 2 abuse allegations reviewed were reported as required. The findings were: 1. Review of the incident/accident report dated 12/2/16 at 2:02 AM for sample resident #2, revealed the following: a. Resident #2 was sitting in his/her room when resident #6 came in and started hitting him/her with a closed fist and ramming his/her lower legs with their walker. b. Review of the progress notes dated 12/2/16 at 2:02 AM showed Resident is terrified of being attacked again. Review of the nursing notes dated 12/2/16 at 3:16 PM showed, Multiple bruises noted to bilateral lower extremities (BLE) and bilateral upper extremities (BUE). Bruise noted to left temporal area, and around left eye. Skin tear noted to right shin. The on-call doctor was notified at 2 AM and the son of resident #2 was notified on 12/2/16 at 2:00 PM. c. Interview with the administrator on 12/14/16 at 4:20 PM verified he intended to notify the State Survey Agency of the allegation of abuse, however, he had no verification of the report. Review of the incident logs maintained by the State Survey Agency failed to show the incident of abuse was reported. 2. Review of the incident/accident report showed on 12/9/16 at 7:00 PM resident #4 and resident #6 had an altercation. Resident #6 had hit resident #4 in the face twice and there were no injuries noted. Review of the progress notes on 12/10/16 3:30 AM showed, Resident (#6) denies injury and stated s/he is the one that punched the other resident. Resident is on neuros (neurological checks) due to this and s/he has refused all vital signs tonight. No change in neuro status from his baseline. Resident is angry, inappropriate and verbally aggressive. The following concerns were identified: a. Review of the report information showed the State Survey Agency was not notified of the abuse allegation until 12/12/16. b. Inte… | 2019-11-01 |
| 1092 | 1092 | CASPER MOUNTAIN REHABILITATION AND CARE CENTER | 535024 | 4305 S POPLAR | CASPER | WY | 82601 | 2016-12-15 | 257 | E | 1 | 0 | 0KN611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, resident interview, and review of maintenance notes, the facility failed to ensure the temperature in 3 of 7 resident areas (secured unit/500 hall, 600 hall, main dining room) was safe and comfortable. The findings were: Observation of the secured unit/500 hall on 12/13/16 at 2:50 PM showed there were two thermostats on the wall, one near room [ROOM NUMBER] and one near the exit to the 600 hallway. The thermostat near room [ROOM NUMBER] showed 65 degrees Fahrenheit (F) when observed at 2:50 PM. The thermostat near the 600 hallway exit was digital and showed 72 degrees F when observed at 3:01 PM. The temperature of the area felt cold and the residents who were in bed were noted to have several blankets. Observation of the 600 hall on 12/13/16 at 3:04 PM showed the temperature as measured with an infrared thermometer was 69.3 degrees F and a cold draft could be felt coming from a ceiling vent in the area between rooms [ROOM NUMBERS]. Observation in room [ROOM NUMBER] at 3:04 PM showed the room felt cold, and the window could not fully closed or latched and leaked cold air into the room. The thermostat near the door of the room showed the temperature was 68 degrees F. Observation on 12/13/16 at 5:23 PM showed room [ROOM NUMBER] felt cold. The resident was not in the room, and there was no thermostat in the room, however, when measured with an infrared thermometer the wall by the head of the bed measured 65.5 degrees F. The window in this room was leaking cold air; a draft at the bottom of the window could be felt. Observation of the main dining room on 12/14/16 at 4:35 PM showed the evening meal service was in process. There were 9 residents observed in the dining room wearing coats and some wore winter hats as well. Interview at that time with 2 of the residents wearing coats revealed they were cold and had been cold for several days. There was an open vent on the ceiling in the room letting in the cold … | 2019-11-01 |
| 1093 | 1093 | CASPER MOUNTAIN REHABILITATION AND CARE CENTER | 535024 | 4305 S POPLAR | CASPER | WY | 82601 | 2016-12-15 | 309 | G | 1 | 0 | 0KN611 | > Based on observation, medical record review, and staff interview, the facility failed to ensure care and services were provided to maintain/attain the highest practicable physical well-being for 1 of 7 sample residents (#7). This failure resulted in a negative outcome for the resident who developed multi-location skin breakdown. The findings were: Review of the 10/25/16 annual MDS assessment showed resident #7 required extensive assistance for ADLs, and was at risk for pressure ulcers. Further review showed the resident did not have any pressure ulcers at the time of the assessment. Review of the pressure ulcer CAA showed chronic health conditions such as incontinence, inability to perform ADLs without significant physical assistance, existing pressure ulcer(s), and extrinsic risk factors (pressure) contributed to the problem. Review of the care plan related to skin issues showed it was initiated on 2/1/16. The resident had risk factors related to impaired mobility, incontinence, use of assistive devices (wheelchair), and a history of open areas. Interventions included an air mattress with an initiation date of 5/13/16. The following concerns were identified: a. Confidential interview with staff #1 on 12/14/16 revealed the 500 hallway where resident #7 lived was cold due to problems with the heat system. The staff stated the problem had been ongoing since Saturday 12/10/16, and the temperatures were so cold resident #7 was brought out of his/her room and into the main area to sleep on a mattress on the floor for 2 nights (12/10/16 and 12/11/16) and be warmed up. b. Confidential interview with staff #2 on 12/14/16 revealed residents on the secured unit had been uncomfortable and complaining of the cold temperatures. The staff member reported the temperatures were uncomfortably cold on Friday 12/9/16, Saturday 12/10/16, and Sunday 12/11/16, and resident #7 was brought into the milieu to sleep on a mattress on the floor Saturday and Sunday due to the resident's room being so cold and the resident freezing. c. Conf… | 2019-11-01 |
| 1094 | 1094 | CASPER MOUNTAIN REHABILITATION AND CARE CENTER | 535024 | 4305 S POPLAR | CASPER | WY | 82601 | 2016-12-15 | 371 | E | 1 | 0 | 0KN611 | > Based on observation and staff interview, the facility failed to ensure sanitary requirements were met related to dating of health shakes and cleanliness of equipment in 1 of 2 food storage/service areas (the main kitchen). The findings were: 1. Observation on 12/13/16 at 3:36 PM showed thawed health shakes were stored in a refrigerator unit in the main kitchen. There were more than 20 individual cartons of thawed shakes and the pan they were in showed a date of 12/9/16. Interview with the dietary manager and the corporate culinary/nutritional service staff member on 12/14/16 at 12:07 PM verified a system was needed to date mark the shakes so others knew when they were to be used by or discarded. According to the labels on the health shakes, they are to be used within 14 days of being thawed. 2. Observation on 12/13/16 at 3:46 PM and 12/14/16 at 11:25 AM showed the vents in the hood above the range/grill were rusted. There were 4 vents with visible rust located above this food preparation area. Interview with the dietary manager and the corporate culinary/nutritional service staff member on 12/14/16 at 12:07 PM verified the rusted vents needed to be replaced. 3. Observation on 12/13/16 at 3:46 PM and 12/14/16 at 11:25 AM showed the floor throughout the kitchen was soiled and sticky. Additionally, the outside of two refrigerator units around the handles were soiled with stuck-on food debris and grime. Interview with the dietary manager and the corporate culinary/nutritional service staff member on 12/14/16 at 12:07 PM verified the floors were scheduled to be mopped after each meal and the outside of equipment should be wiped down daily. At 4:10 PM the dietary manager and the corporate staff member stated additional accountability was needed to ensure the tasks were being completed on the cleaning schedule. According to Food Code 2013, U.S. Public Health Service: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to si… | 2019-11-01 |
| 1095 | 1095 | CASPER MOUNTAIN REHABILITATION AND CARE CENTER | 535024 | 4305 S POPLAR | CASPER | WY | 82601 | 2016-12-15 | 465 | D | 1 | 0 | 0KN611 | > Based on observation and staff interview, the facility failed to ensure a comfortable environment for staff in 3 random areas (the kitchen, the secured unit, the laundry room). The findings were: 1. Observation on 12/14/16 at 12 PM showed the kitchen/dish room area felt cold. When the wall near the handwashing sink was measured with an infrared thermometer, the temperature measured 63.5 degrees F. The dietary manager stated a delivery was received at approximately 8 AM that morning and when the door was open it became more cold. There was also noticeable cold air coming in from the ceiling vents in the dish room and the dining room which was open to the kitchen. 2. Observation on 12/14/15 at 3:55 PM showed the laundry room felt cold. There were no staff working in the area at that time. However, there was a large ceiling vent which was uncovered and cold air from the outside came in. 3. Observation of the secured unit/500 hall on 12/13/16 at 2:50 PM showed the thermostat on the wall one near room 509 showed 65 degrees Fahrenheit (F) when observed at 2:50 PM. Interview with housekeeping staff at that time stated it was cold in the unit and had been over the weekend. Interview with staff member #3 on 12/14/16 verified the temperature in the secured unit had been cold for days due to problems with the boiler. 4. Interview with the maintenance staff member on 12/15/16 at 8:55 AM revealed she was the only maintenance staff member since the maintenance director's last day on 12/5/16. The staff member verified the boiler in the back area had gone down over the weekend. The staff member addressed the issue beginning Monday 12/12/16 and work was started to repair the boiler for heat. The maintenance staff further revealed the 5 evaporative cooling units on the roof had not been covered to prevent cold air from coming into the building. 5. Interview with the administrator on 12/15/16 at 12:34 PM verified there was not a scheduled plan for when the cooling system was to be winterized. | 2019-11-01 |
| 501 | 501 | ROCKY MOUNTAIN CARE - EVANSTON | 535038 | 475 YELLOW CREEK ROAD | EVANSTON | WY | 82930 | 2019-06-06 | 600 | D | 0 | 1 | 0P7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review, the facility failed to ensure 1 of 4 sample residents (#42) identified in reported allegations of resident to resident abuse was free from abuse. This failure resulted in recurrent incidents of resident #13 punching and kicking resident #42. The findings were: Review of the 3/12/19 annual MDS assessment showed resident #13 had a BIMS score of 12/15 (moderate cognitive impairment) and [DIAGNOSES REDACTED]. Further review showed the resident required extensive assistance with bed mobility, dressing, and transfers. Review of the care plan, last updated 4/24/19, showed the resident could self propel his/her wheelchair independently and staff were to set firm limits on behaviors. Review of the 4/29/19 quarterly MDS assessment for resident #42 showed s/he had a BIMS score of 1/15 (severe cognitive impairment); [DIAGNOSES REDACTED]. The following concerns were identified: a. Review of incident/accident investigations showed resident #13 punched resident #42 on 4/22/19. This review showed both residents were in their wheelchairs in the hallway and the incident occurred before staff who were present at that time could prevent it. Interview on 6/6/19 at 9:20 AM with the administrator revealed no major injuries resulted from the incident; and staff determined they would prevent close contact between the residents. Review of the investigation documentation showed the incident was reported to all appropriate agencies, family, and physician in timely manner. b. Review of incident/accident investigations showed resident #13 kicked resident #42 on 5/14/19 in the dining room and no serious injuries resulted from this. Further review showed at the time of the incident, the nursing school instructor was wheeling resident #42 and did not know she should not move the resident in an area close to resident #13. Review of the investigation documentation showed the incident was reported to all appropriate agencies, … | 2020-09-01 |
| 502 | 502 | ROCKY MOUNTAIN CARE - EVANSTON | 535038 | 475 YELLOW CREEK ROAD | EVANSTON | WY | 82930 | 2019-06-06 | 684 | D | 0 | 1 | 0P7L11 | Based on observation, medical record review and staff interview, the facility failed to ensure needed care and services that met each resident's highest practicable physical, mental, and psychosocial well-being were provided for 1 of 24 sample residents (#198). The findings were: Review of the 5/8/19 care plan for resident #198 showed the following: The interventions for impaired ability to participate included encourage simple activities and attempt simple interactions. The interventions for pressure ulcers included staff will assist with toileting and peri-care. The interventions for function and rehab included use wheelchair for locomotion. The following concerns were identified: a. Intermittent observation on 6/4/19 showed the resident remained in bed, in the same supine position from 8:55 AM until end of observations at 3:53 PM. Extended observation of the resident on 6/5/19 from 12:40 PM to 4:50 PM showed the only staff to enter the room during this time period was a dietary aide to leave and pick up meal tray. The resident was in bed, in supine position with the covers up. b. During an interview on 6/5/19 at 11:32 AM RN #2 revealed she was unable to access the resident's care plan in the computer but knew the resident was on palliative care, stayed in bed all of the time, and that toileting was done as we can. c. During an interview on 6/6/19 at 9:15 AM CNA #1 revealed the expectation was for direct care staff to check and change bed-bound residents every two hours. d. During an interview on 6/6/19 at 9:35 AM, the ADON revealed the facility expectation was to check and change the bed-bound resident for incontinence every two hours. | 2020-09-01 |
| 503 | 503 | ROCKY MOUNTAIN CARE - EVANSTON | 535038 | 475 YELLOW CREEK ROAD | EVANSTON | WY | 82930 | 2019-06-06 | 697 | D | 0 | 1 | 0P7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview and medical record review, the facility failed to implement effective pain management for 1 of 1 sample resident (#9) reviewed for pain management. The findings were: Review of the 2/27/19 quarterly MDS assessment for resident #9 showed s/he had a BIMS score of 14/15 (cognitively Intact) and required extensive assistance with activities of daily living. This review also showed the resident had [MEDICAL CONDITION] due to a stroke and frequent pain. Review of the 2019 (MONTH) recapitulation of physician orders [REDACTED]. Interview on 6/4/19 at 2:15 PM with the resident revealed s/he had a lot of pain and sometimes the pain pills helped and sometimes they did not provide complete relief. The resident further stated his/her left leg hurt a lot and lower back hurts too. On 6/6/19 at 9:45 AM, the pain Medication Administration Record [REDACTED]. This review showed the pain medication was administered on 5/14/19, 5/20/19, 5/21/19, 5/22/19, 5/27/19, and 5/29/19. Further review showed an assessment prior to the medication administration or an assessment after the medication was administered was not done or neither was completed for the above dates. Interview with the DON on 6/6/19 at 10:15 AM revealed staff were aware of the resident's pain and had tried various interventions to address his/her pain. The DON further stated the resident's pain was hard to assess. | 2020-09-01 |
| 504 | 504 | ROCKY MOUNTAIN CARE - EVANSTON | 535038 | 475 YELLOW CREEK ROAD | EVANSTON | WY | 82930 | 2019-06-06 | 812 | E | 0 | 1 | 0P7L11 | Based on observation and staff interview the facility failed to ensure food safety requirements were met and sanitary conditions were maintained in the kitchen during 2 of 2 observations of the kitchen. The findings were: 1. Observation of the ice machine in the kitchen on 6/5/19 at 4:30 PM revealed the upper interior area was dirty. At that time the CDM moved a clean cloth across the area and removed a black and brown substance. Interview on 6/06/19 at 9:20 AM with the maintenance supervisor, revealed he was responsible for cleaning the ice machine once a month and last did it on 5/3/19. He further stated he might need to revise the cleaning schedule and perform the task more frequently. 2. Observation on 6/6/19 from 7:20 AM to 8:30 AM showed 3 packaged herb rubbed pre-cooked turkey breasts, one package of sliced ham and a partially thawed 30 ounce container of frozen basil were in a pan on the countertop near the sink. The packaged meats and container of basil sat in the thawing moisture in the pan. At 8:35 AM, the CDM said the turkey was to be prepared for the noon meal and the ham for the supper meal later that day, but staff had not had an opportunity to cut it up. She further stated she did not know how long the meat had been on the counter and it should have been in the refrigerator until ready for use. Review of the menu directions for the meat showed instructions to Thaw meat under refrigerator (41 F). 3. On 6/6/19 at 7:20 AM observation showed 6 shelving units used for storage of dishes, pans, condiments, bread and bananas had lint and dust threads covering the wired structures on all of the two lower shelves of each unit. At 8:35 AM, the CDM observed the shelves and verified they needed to be cleaned. She further stated her staff were responsible for cleaning the shelves and it had been overlooked. 4. According to Food Code (YEAR), U.S. Public Health Service: 4-601.11 (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment a… | 2020-09-01 |
| 321 | 321 | CROOK COUNTY MEDICAL SERVICES DISTRICT LTC | 535029 | 713 OAK STREET | SUNDANCE | WY | 82729 | 2018-03-16 | 604 | E | 0 | 1 | 0UE711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure 3 of 12 sample residents (#12, #15, #24) were free from unnecessary physical restraints. The findings were: 1. Observation on 3/12/18 at 3:03 PM showed resident #12 was in bed with a bed rail in use on the upper right side of the bed and a wedge device secured to the left side of the bed. The following concerns were identified: a. Review of the quarterly MDS assessment dated [DATE] showed the resident had [DIAGNOSES REDACTED]. Further, the resident required total assistance of 2 staff members for bed mobility. b. Review of a physical restraint evaluation completed on 2/8/18 showed the device was used for boundary identification because the resident was immobile and required total assistance. There was no evidence the resident had been evaluated to determine the least restrictive device or identify safety risks. c. Interview with the DON on 3/15/18 at 10:06 AM revealed the wedge was implemented because the resident would curl up into a ball and almost fall out of bed. Continued interview revealed the resident was unable to remove the wedge without assistance. 2. Observation on 3/12/18 at 3:32 PM showed resident #24 was in bed with the right side of the bed pushed up against the wall and a wedge placed behind the resident on the left side of the bed. Further, the resident had an alarm attached to his/her shirt which was secured to the head of the bed. Observation on 3/14/18 at 9:23 AM showed the resident was in bed with the right side of the bed pushed up against the wall and a wedge placed behind the resident on the left side of the bed. At that time, the resident had an alarm attached to his/her shirt which was secured to the head of the bed. The following concerns were identified: a. Review of the 12/7/17 quarterly MDS assessment showed the resident had [DIAGNOSES REDACTED]. Further, the resident required extensive assistance of 2 staff members fo… | 2020-09-01 |
| 322 | 322 | CROOK COUNTY MEDICAL SERVICES DISTRICT LTC | 535029 | 713 OAK STREET | SUNDANCE | WY | 82729 | 2018-03-16 | 637 | D | 1 | 1 | 0UE711 | > Based on medical record review and staff interview, the facility failed to ensure a significant change assessment was completed for 1 of 13 sample residents (#130) reviewed for change in condition. The findings were: Review of the 6/13/17 admission MDS assessment showed resident #130 had moderately impaired cognition, independent activities of daily living, no psychiatric medication, and no behaviors. The following concerns were identified: a. Review of the medication orders showed the physician ordered daily doses of Klonopine for the resident's behaviors on 7/26/17. b. Review of the 6/30/17 nursing note showed the resident was friendly and pleasant but resistant to baths, Angers if friend is upset, incontinent of bowel and bladder, wandered from door to door looking for a way out to go home and needed frequent redirection. c. Review of the 7/1/17 nursing note showed the resident was alert, confused, agitated, and redirected out of other resident rooms. The resident wore a Wanderguard and had poor safety awareness. The resident was looking for a way home. d. Review of the 7/5/17 nursing note showed the resident wandered throughout the facility, was an elopement risk, and became agitated when staff redirected him/her. e. Review of the 8/7/17 nursing note showed the resident was uncooperative, refused care, was threatening to visitors and staff, and difficult to reason with. During an interview on 3/15/18 at 10:52 AM, the MDS coordinator acknowledged the changes in the resident's behavior and addition of the psychiatric medication that were noted after she developed the admission MDS assessment and prior to the resident's discharge in (MONTH) (YEAR). She further stated she did not develop a significant change MDS to address the changes because this was the only area of change for the resident. | 2020-09-01 |
| 323 | 323 | CROOK COUNTY MEDICAL SERVICES DISTRICT LTC | 535029 | 713 OAK STREET | SUNDANCE | WY | 82729 | 2018-03-16 | 656 | E | 0 | 1 | 0UE711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff and resident interview, the facility failed to develop a are plan for 7 of 12 sample residents (#12, #13, #16, #21, #24, #28, #132) who had bed rails and/or restraints. The findings were: 1. Observation on 3/12/18 at 3:03 PM showed resident #12 was in bed with a half bed rail in use on the upper right side of the bed and a wedge device secured to the left side of the bed. Review of the quarterly MDS assessment dated [DATE] showed the resident had [DIAGNOSES REDACTED]. Further, the resident required total assistance of 2 staff members for bed mobility. Review of a physical restraint evaluation completed on 2/8/18 showed the device was used for boundary identification because the resident was immobile and required total assistance. Review of the care plan, last revised on 12/31/17, showed no evidence the bed rail or wedge was care-planned for appropriate use or safety concerns. 2. Observation on 3/12/18 at 3:32 PM showed resident #24 was in bed with the right side of the bed pushed up against the wall and a bolster pillow behind the resident on the left side of the bed. Further, the resident had an alarm attached to his/her shirt which was secured to the head of the bed. Observation on 3/14/18 at 9:23 AM showed the resident was in bed with the right side of the bed pushed up against the wall and a bolster pillow placed behind the resident on the left side of the bed. At that time, the resident had an alarm attached to his/her shirt which was secured to the head of the bed. Review of the 12/7/17 quarterly MDS assessment showed the resident had [DIAGNOSES REDACTED]. Further, the resident required extensive assistance of 2 staff members for bed mobility. Review of a physical restraint evaluation dated 3/14/18 showed the bolster pillow was used for boundary identification because the resident was immobile and required staff to move him/her. Review of the care plan, last revised on 12/31/17, sho… | 2020-09-01 |
| 324 | 324 | CROOK COUNTY MEDICAL SERVICES DISTRICT LTC | 535029 | 713 OAK STREET | SUNDANCE | WY | 82729 | 2018-03-16 | 686 | D | 0 | 1 | 0UE711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview the facility failed to develop an effective system for monitoring pressure ulcers for 1 of 1 sample resident (#131) with pressure ulcers. Review of the medical record showed resident #131 was admit on 2/20/18 and the nursing admission assessment showed the resident had a healed pressure ulcer on the sacrum. Review of the 3/5/18 admission MDS assessment showed s/he had [DIAGNOSES REDACTED]. Further review revealed s/he was at risk for developing pressure ulcers, but did not have any pressure ulcers. The resident required limited assistance with most activities of daily living. The following concerns were identified: a. Observation of the resident on 3/14/18 at 10 AM revealed the resident had a stage II open area on the coccyx gluteal fold. b. Review of the 3/9/18 nursing notes showed the resident had a 0.5 cm x 0.2 cm pressure ulcer noted to her coccyx in the gluteal fold: Wound presents as a stage 1. Wound bed is covered with a thin fragile layer of [MEDICATION NAME] cells. Area is light pink and non-blanching at this time. no drainage and no odor noted at this time. Area was cleansed with warm soapy water, patted dry, skin prep applied to peri-wound, and a [MEDICATION NAME] dressing was placed. c. Review of the 3/13/18 nursing notes showed the resident had a 0.4 cm x 0.2 cm x 0.1 cm stage 2 pressure ulcer noted to her coccyx in gluteal fold: Wound was opened up. Edges are regular. Wound bed was clean light pink. small amount of serosanguineous drainage was noted to [MEDICATION NAME]. No odor noted at this time. Peri-wound is a medium red color and blanching. Area was cleansed with warm soapy water, patted dry, skin prep applied to peri-wound, and a bordered duoderm dressing was placed. Resident stated the wound was tender. d. Review of the facility's skin care monitoring system for the resident revealed inconsistent documentation, making it difficult to determine when the pressu… | 2020-09-01 |
| 325 | 325 | CROOK COUNTY MEDICAL SERVICES DISTRICT LTC | 535029 | 713 OAK STREET | SUNDANCE | WY | 82729 | 2018-03-16 | 700 | E | 0 | 1 | 0UE711 | Based on observation, medical record review, and resident and staff interview, the facility failed to ensure all were met for 6 sample residents (#12, #13, #16, #21, #28, #132 ) who had bed rails. The findings were: 1. Observation on 3/12/18 at 3:03 PM showed resident #12 was in bed with a bed rail in use on the upper right side of the bed and a wedge device secured to the left side of the bed. Observation on 3/14/18 at 4:34 PM showed the bed rail was designed to have 4 gaps which each measured 3 inches in height by 6 inches in width. The following concerns were identified: a. Review of the Side Rail Evaluation dated 2/8/18 showed the resident was totally dependent on staff to get in and out of bed and for all ADLs. Further review showed no evidence that the bed rails were assessed for entrapment or that informed consent for a bed rail was obtained. 2. Observation on 3/12/18 at 3:48 PM showed resident #13's bed had half bed rails which were in use on the upper portion of the bed on both sides. Observation on 3/14/18 at 4:34 PM showed the bed rails were designed to have 2 gaps which measured 5 1/2 inches in height by 7 inches in width and 2 gaps which measured 7 1/2 inches in height by 2 inches in width. The following concerns were identified: a. Review of the Side Rail Evaluation dated 2/7/18 showed the resident required limited assistance of staff to get in and out of bed and the resident requested the use of bed rails. Further review showed no evidence that the bed rails were assessed for entrapment or that informed consent for a bed rail was obtained. 3. Observation on 3/13/18 at 10:21 AM showed resident #132's bed had a half bed rail in use on the upper left side of the bed which was against the wall. Observation on 3/14/18 at 4:34 PM showed the resident's bed had half bed rails in use on the upper portion of the bed, on both sides. The bed rails were designed to have 2 gaps which measured 4 inches in height by 7 inches in width and 1 gap which measured 4 1/2 inches in height and 2 inches in width. The follow… | 2020-09-01 |
| 326 | 326 | CROOK COUNTY MEDICAL SERVICES DISTRICT LTC | 535029 | 713 OAK STREET | SUNDANCE | WY | 82729 | 2018-03-16 | 812 | E | 0 | 1 | 0UE711 | Based on observation and staff interview, the facility failed to ensure food was stored in a sanitary environment in 1 of 1 food preparation area (main kitchen). The findings were: 1. Observation of the walk-in cooler on 3/12/18 at 2:42 PM showed an opened bag of sliced onions that did not have a label or use by date. 2. Observation of the dry storage room on 3/12/18 at 2:45 PM showed a clear plastic bag labeled vanilla pudding which had a white powdery substance in it and had an expiration date of 3/2/18. Further observation showed a clear plastic bag labeled pudding mix which had an off-white colored powdery substance in it and had an expiration date of 1/8/18. Observation on 3/14/18 at 11:24 AM showed the vanilla pudding and pudding mix were still in the storage area. 3. Interview with the dietary manager on 3/14/18 at 11:24 AM revealed stored items should always have labels and an expiration date. Further, she confirmed that all items in the dry storage and the refrigerators were available for resident consumption. 4. According to Food Code 2013, U.S. Public Health Service: 3-501.17 (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under 3-502.12, and except as specified in (D) and (E) of this section, refrigerated, READY-TO -EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. | 2020-09-01 |
| 327 | 327 | CROOK COUNTY MEDICAL SERVICES DISTRICT LTC | 535029 | 713 OAK STREET | SUNDANCE | WY | 82729 | 2018-03-16 | 880 | D | 0 | 1 | 0UE711 | Based on observation, staff interview, and policy and procedure review, the facility failed to ensure hand hygiene was performed for 1 of 7 sample residents (#19) who received incontinence care. The findings were: Observation on 3/13/18 at 11:02 AM showed CNA #1 entered the room of resident #19, donned gloves, and provided perineal care to the resident, who had been incontinent of bladder. After performing the care, the CNA removed the gloves and repositioned the resident. Without performing hand hygiene, the CNA took a bag of trash out of the room, walked down the hallway, and entered the soiled utility room. Upon leaving the soiled utility room, the CNA used hand sanitizer gel and then entered another resident room to perform care. Interview with the infection preventionist on 3/15/18 at 11:18 AM revealed handwashing should be performed when hands are visibly soiled or dirty, when the resident has a suspected organism, or when leaving the bathroom. Review of the facility's policy titled Handwashing/Hand Hygiene last revised 4/2012 showed .5. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: .c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); .h. Before and after assisting a resident with personal care (e.g., oral care, bathing); .n. Before and after assisting a resident with toileting (hand washing with soap and water); .q. After contact with a resident's mucous membranes and body fluids or excretions; .u. After removing gloves or aprons; . | 2020-09-01 |
| 408 | 408 | LIFE CARE CENTER OF CHEYENNE | 535032 | 1330 PRAIRIE AVENUE | CHEYENNE | WY | 82009 | 2017-03-23 | 156 | B | 0 | 1 | 12VP11 | Based on observation and staff interview the facility failed to post the required notices in a form and manner readily accessible to residents and resident representatives. The census was 143. The findings were: Observation of the facility during the survey timeframe showed the names, addresses, and phone numbers of all pertinent State agencies and advocacy groups were listed on an 8 by 11 inch framed document located on a table in the main entrance vestibule. The doors into the vestibule from the facility remain locked at all times and required the manual depression of a red button to open them, which made this document inaccessible to residents. In addition, the document did not contain the required email addresses or a statement to show residents may file a complaint with the State Survey Agency. The administrator declined to comment during an interview on 3/23/17 at 12 PM. | 2020-09-01 |
| 409 | 409 | LIFE CARE CENTER OF CHEYENNE | 535032 | 1330 PRAIRIE AVENUE | CHEYENNE | WY | 82009 | 2017-03-23 | 166 | B | 0 | 1 | 12VP11 | Based on staff interview and review of policy and procedure, the facility failed to ensure the grievance policy contained all the required information. The census was 143. The findings were: Review of Grievance Procedures, last revised 11/19/16, showed the policy failed to include required information including the name, address, and phone number of the grievance official, the expected time frame for completion of the grievance, the contact information of independent entities with whom a grievance could also be filed, and did not address the right to file a grievance anonymously. Interview with the administrator on 3/23/17 at 10:10 AM confirmed the policy and procedure did not contain all necessary information. | 2020-09-01 |
| 410 | 410 | LIFE CARE CENTER OF CHEYENNE | 535032 | 1330 PRAIRIE AVENUE | CHEYENNE | WY | 82009 | 2017-03-23 | 274 | D | 0 | 1 | 12VP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the CMS RAI version 3.0 manual, the facility failed to ensure a significant change assessment was completed for 2 of 5 sample residents (#40, #110) with a significant change. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #40 at section 1300 D (Psychomotor [MEDICAL CONDITION]) was coded as behavior fluctuates. Further review showed the resident had a depression score of 6 (mild), verbal behavior symptoms directed towards others that occurred 1 to 3 days, other behavioral symptoms not directed at others that occurred 1 to 3 days, no functional range of motion limitations in range of motion in upper extremities, occasional as needed pain medications, occasional pain with a numeric score of 4 out of 10, non-physician prescribed weight loss, use of antipsychotic medication for 6 days, use of antianxiety medication for 7 days, and use of antidepressant medication for 7 days during the assessment period. The following concerns were identified: a. Review of the admission MDS assessment dated [DATE] showed the resident had no behaviors present for section 1300 D, had a depression score of 4 (minimal), no verbal behavioral symptoms directed towards others, no other behavioral symptoms not directed at others, functional limitations of both upper extremities, no as needed pain medication, no identified pain, no weight loss, and no antipsychotic, antianxiety, or antidepressant medication use during the assessment period. b. Interview with MDS coordinator #1, MDS coordinator #2, MDS coordinator #3 and the social services director on 3/23/17 at 12:16 PM confirmed a significant change assessment should have been completed. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #110 sometimes made self understood, had a BIMS score of 8 (moderately impaired), a depression score of 3 (minimal), was continent of bowel, had scheduled pain med… | 2020-09-01 |
| 411 | 411 | LIFE CARE CENTER OF CHEYENNE | 535032 | 1330 PRAIRIE AVENUE | CHEYENNE | WY | 82009 | 2017-03-23 | 279 | D | 0 | 1 | 12VP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview the facility failed to ensure a comprehensive care plan was developed on resident needs for 1 of 21 sample residents (#85). The findings were: 1. Review of the 1/9/17 quarterly MDS assessment showed resident #85 had [DIAGNOSES REDACTED]. The resident required the extensive assistance of 2 staff members for bed mobility, transfers, dressing, and toileting. Review of the 1/4/17 Braden scale assessment for predicting pressure sore risk showed the resident scored 14 (moderate risk). The following concerns were identified: a. Observation on 3/20/17 at 2:10 PM showed the resident was in his/her wheelchair in the dining room attending an activity. The resident's right foot was supported by a foot trough, and a left trunk support pad and bilateral arm rest pads were on the wheelchair. At 3:35 PM the resident was brought to his/her room for a blood sugar check. At 4:20 PM CNA #1 returned the resident to the dining room for the evening meal. At 5:32 PM the resident was brought back to his/her room by CNA #2. Continued observation until 6:05 PM showed the resident had not been repositioned for 4 hours. b. Review of the 1/19/17 care plan section Risk for Pressure Ulcers showed approaches which included weekly skin assessments, quarterly Braden scale assessments, floated heels while in bed, and pressure relieving or reduction devices to the bed and wheelchair. The care plan failed to address the need for repositioning. c. Interview on 3/22/17 at 3:30 PM with LPN #2 revealed the resident was transferred with a sit-to-stand lift and was totally dependent on staff for mobility. d. Interview with the DON on 3/23/17 at 12:12 PM confirmed the resident's care plan did not include repositioning as an intervention to prevent pressure ulcers and, in addition, it was his expectation that residents at risk for developing pressure injuries be repositioned every two hours. | 2020-09-01 |
| 412 | 412 | LIFE CARE CENTER OF CHEYENNE | 535032 | 1330 PRAIRIE AVENUE | CHEYENNE | WY | 82009 | 2017-03-23 | 282 | D | 0 | 1 | 12VP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview the facility failed to ensure plans of care were followed as written for 2 of 21 sample residents (#66, #27). The findings were: 1. Review of the 1/5/17 quarterly MDS assessment showed resident #66 had moisture associated skin damage, was frequently incontinent, and required extensive assistance with toileting. Review of the resident's care plan for incontinence showed approaches that included instructions for staff to toilet upon rising, before and after meals, at bedtime and as needed. The following concerns were identified: a. Continuous observation on 3/20/17 beginning at 2 PM and ending at 5:30 PM (3 1/2 hours) showed the resident was seated in a wheelchair. The resident was in the dining room from 2 PM until 4 PM. At 4 PM LPN #1 brought the resident to his/her room for medication administration and then returned him/her back to the dining room without toileting him/her. At 4:45 PM the resident was served dinner. At 5:30 PM the resident finished dinner and remained in the dining room. At no time during the observation did staff offer to toilet the resident. b. Interview with LPN #1 on 03/20/17 at 4 PM revealed the resident was to be toileted before and after meals and at bedtime. In addition, she stated the resident required total lift assistance from staff. c. Interview on 3/21/17 at 1 PM, with RN #2 revealed The resident does have stress incontinence and can also tell us when s/he needs to use the bathroom. We take him/her to the bathroom before and after meals and at bedtime. d. Interview on 3/23/17 at 12:12 PM with the DON revealed it was his expectation staff would toilet residents per the care plan. 2. Review of the 3/5/17 significant change MDS assessment for resident #27 showed the resident had [DIAGNOSES REDACTED]., [MEDICAL CONDITION] disorder, [DIAGNOSES REDACTED], and had a left lower extremity fracture. The resident required extensive assistance of 2 staff memb… | 2020-09-01 |
| 413 | 413 | LIFE CARE CENTER OF CHEYENNE | 535032 | 1330 PRAIRIE AVENUE | CHEYENNE | WY | 82009 | 2017-03-23 | 371 | E | 0 | 1 | 12VP11 | Based on observation, staff interview, and review of maintenance records, the facility failed to ensure 2 of 2 ice machines (main, Arrowhead) were maintained in a sanitary condition. The findings were: Observation on 3/20/17 at 9:10 AM of the ice machine in the main kitchen showed the interior of the lid was soiled with discolored debris. Further, the ice machine in the Arrowhead kitchen area showed a build-up of discolored debris on the interior surfaces and the fan/vent was covered in dust. Additional observation on 3/22/17 at 11:05 AM showed the ice machine in the kitchen remained unsanitary with the debris on the interior of the lid and the area around the hinges of the lid. Observation on 3/22/17 at 11:48 AM of the ice machine located in the Arrowhead kitchen showed it remain unsanitary. There was a yellow colored substance which appeared slimy across the surface of the ice-making mechanism located above the ice bin. Interview with the dietary manager on 3/22/17 at 12:48 PM verified the machines were in need of cleaning. She stated the maintenance department was responsible for the sanitation. Interview with the maintenance director on 3/23/17 at 9:40 AM verified the ice machines were sanitized every 3 months. Review of the maintenance record showed the machines were last sanitized on 12/15/16 and due again on 3/31/17. The record did not show separate entries for when maintenance/cleaning was done, it referred to Ice Machines. According to the director the schedule was to clean/sanitize both at the same time. He further verified the machines should be kept sanitary and there may be times when sanitization/cleaning was needed between the scheduled times. According to Food Code 2013, U.S. Public Health Service: 4-602.11 .(E) Except when dry cleaning methods are used as specified under 4-603.11, surfaces of UTENSILS and EQUIPMENT contacting FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned: (4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUI… | 2020-09-01 |
| 414 | 414 | LIFE CARE CENTER OF CHEYENNE | 535032 | 1330 PRAIRIE AVENUE | CHEYENNE | WY | 82009 | 2017-03-23 | 431 | E | 0 | 1 | 12VP11 | Based on observation and staff interview, the facility failed to discard expired medications for 3 of 7 medication carts (Hall 400 medication cart, Southwest medication cart, Therapy Center medication cart). The findings were: 1. Observation on 3/23/17 at 10:51 AM of the medication cart in hall #400 with RN #3 revealed the following: a. A bottle of the medication Simethicone 80 milligrams (mg) had an opened date of 8/16/16 and had an expiration date of 2/17. b. A bottle of the medication Selonium 200 micrograms had an opened date of 8/11/16 and an expiration date of 1/17. 2. Observation of the Southwest medication cart on 6/23/17 at 10:25 AM revealed a bottle of Simethicone 80 mg had an expiration date of 06/16. The medication was available for use. 3. Observation of the Therapy Center West cart on 6/23/17 at 11 AM revealed a bottle of liquid Nystatin 100,000 u/ml had no expiration date written on the label and was available for use. 4. Interview on 3/23/17 at 10:51 AM with RN #3 and RN #4 revealed the nurses were responsible for ensuring there were no expired medications in the medication carts. They further confirmed the medications Simethicone and Selonium were expired and still available for use. | 2020-09-01 |
| 415 | 415 | LIFE CARE CENTER OF CHEYENNE | 535032 | 1330 PRAIRIE AVENUE | CHEYENNE | WY | 82009 | 2017-03-23 | 502 | E | 0 | 1 | 12VP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and manufacturer instructions, the facility failed to ensure the accuracy of finger stick blood sugar levels obtained by staff. The findings were: 1. Observation on [DATE] at 10:59 AM revealed a medication cart in the 400 hall had a [MEDICATION NAME] glucose control solution box which had an opened date of [DATE]. 2. Observation on [DATE] at 11:20 AM revealed a medication cart in the 500 hall had a [MEDICATION NAME] glucose control solution box which had an expiration date of ,[DATE]. 3. Interview on [DATE] at 10:59 AM and 11:20 AM with RN #4 revealed the night shift nurses check the glucometers on each medication cart and stated the nurses used the [MEDICATION NAME] glucose control solution for calibrating the glucometers. She further confirmed the control solutions in the box with the opened date of [DATE] and the control solutions with the expiration date of ,[DATE] were expired and should have been discarded and not used for calibrating the glucometers. 4. Review of the [MEDICATION NAME] glucose control solutions instructions (pdfstream.manualsonline.com/,[DATE]d-,[DATE]-a796-c 569edc.pdf pg 56, retrieved [DATE]) showed Do not use the control solution if the expiration date has passed. Check the expiration date printed on the control solution bottle. When you open a control solution bottle for the first time, count forward 90 days and write this date on the control solution . Throw away any remaining solution after this date. | 2020-09-01 |
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CREATE TABLE [cms_WY] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );