2024 Year in Review - Wyoming

A facility failed to respond to an abuse allegation involving a CNA who verbally abused and attempted to physically move a resident against their will. Despite the incident being reported and witnessed by staff, the abusive CNA continued to work multiple shifts, and the grievance was not logged or investigated promptly, leading to immediate jeopardy.

Fine: $17,761

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

CNA was suspended pending investigation, an abuse allegation investigation was initiated with resident interviews and reporting to appropriate entities, and all staff received education on abuse reporting and investigation, including training for new staff before resident contact.

A facility failed to provide CPR to a resident in accordance with their POLST, resulting in the resident's death. Staff were unaware of the resident's full code status and did not initiate CPR, believing the resident was a DNR/DNI based on hospital information. The POLST was not found in the disaster recovery binder, and there was no documentation of the resident's condition or physician notification prior to death.

Fine: $22,205

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Corrective actions included staff education on POLST forms and Code Blue procedures, a 100% audit of POLST forms for all residents, verification audits of CPR certification for all licensed nurses, and conducting mock Code Blue drills on every shift.

A resident was physically assaulted by their roommate with a metal clip, resulting in a laceration and bruising that required ER treatment. The incident was witnessed by a CNA who intervened to prevent further harm. Concerns were raised about the appropriateness of rooming arrangements given the victim's disabilities, and the DON admitted to a lack of a performance improvement plan and documentation on managing the aggressor's behavior.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

A resident with severe cognitive impairment was neglected and abused by CNAs in an LTC facility. Surveillance showed a CNA neglecting the resident for 13 hours, while another CNA was caught on video verbally and physically abusing the resident. The resident expressed fear about calling for help after these incidents.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Corrective actions included conducting a resident assessment, suspending the CNA involved, reporting the facility to the adult protection agency, state survey agency, and state board of nursing, and taking disciplinary action against the perpetrators.

A resident with intact cognition was harmed by another resident with severe cognitive impairment in an LTC facility. The incident involved a water cup being thrown, causing physical harm and fear. Immediate actions were taken to separate the residents, but staff training on de-escalation was incomplete, and the incident had not been reviewed in a quality assurance meeting.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

A facility failed to provide appropriate treatment and services for a resident with dementia, resulting in multiple incidents of aggressive behavior, wandering, and incontinence. Despite severe cognitive impairment and documented behavioral issues, the facility did not develop a comprehensive care plan or analyze behavior triggers, leading to actual harm.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility failed to protect residents from abuse by other residents, resulting in harm to three residents. One resident experienced sexual abuse on two occasions, another resident was physically abused resulting in bruising and skin tears, and a third resident was pushed, resulting in a fall and head injury. The facility's documentation and follow-up on these incidents were inadequate.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

A resident with significant cognitive impairment was involved in two separate incidents of physical abuse against other residents, resulting in injury. The first incident led to a fracture for one resident, while the second involved hitting another resident. Both incidents occurred due to inadequate supervision, particularly during shift changes.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

A QAPI program was implemented to address resident-to-resident abuse, with increased observation and 1:1 supervision for the involved resident, staff training on behavior management, and plans to transfer the resident to another facility.

A resident with moderate cognitive impairment and enteritis experienced multiple episodes of vomiting and dehydration, but the facility failed to notify the physician or reassess the condition promptly. The resident was transported to the hospital via facility van without healthcare staff, leading to a collapse and death in the emergency room waiting area.

Fine: $34,333

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

A resident with chronic pain conditions experienced severe pain following a fall, but the facility failed to administer the ordered PRN Oxycodone and did not document the pain level and location. The resident's pain was inadequately managed with only topical gel and routine Tylenol, leading to actual harm and a delayed medical evaluation.

Fine: $25,984

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

A facility failed to protect a resident from verbal abuse by a CNA, who yelled at the resident and attempted to forcibly remove them from a chair. The incident was witnessed by another CNA and an LPN, but the grievance was not properly logged or addressed by the facility, leading to a deficiency in protecting the resident's rights.

Fine: $17,761

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility failed to provide adequate nursing staff, leading to long wait times for resident assistance and missed care activities like showers. Observations and interviews revealed that staffing levels were below required levels, with only two CNAs available for a large number of residents. Payroll data showed low weekend staffing and a one-star staff rating, while Hospitality Aides were incorrectly counted as nursing staff despite being unable to provide direct care.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility did not submit the required PBJ data for the 4th quarter of 2023. This was confirmed during a review and an interview with the business office manager, who stated that she began submitting PBJ data in January, while another staff member was previously responsible. The data for the specified quarter was not submitted.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility did not have a qualified administrator attending QAPI meetings, as the administrator was on leave and not allowed to enter the building. The position remained vacant, and no delegated administrator was in place, as confirmed by the CEO and DON.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility did not submit mandatory staffing data to CMS for a specific quarter. An interview with the DON revealed that the data was not submitted in time, leading to a missed submission. A review of the PBJ confirmed the absence of data submission for the quarter.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility lacked a qualified administrator to manage operations and report to the governing body. Observations and interviews revealed the administrator was on leave for three months without a replacement, and was instructed not to enter the building, hindering effective management.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility failed to maintain the Ecolab ES-4000 dishwasher at the required temperature, as observed in the kitchen. Dietary aides reported water temperatures below the recommended 120 degrees Fahrenheit, with logs showing compliance only a few times. The facility's policy and FDA guidelines emphasize the importance of maintaining specific temperatures for effective sanitization, yet the issue persisted despite awareness by maintenance and the Ecolab technician.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility failed to have a licensed administrator on-site, as the current administrator lived in a different town and was employed elsewhere. Observations showed an unlicensed administrator in training managing the facility, while the licensed administrator communicated via email and phone. The previous administrator was on leave, and the current administrator had never visited the facility.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility failed to maintain a sanitary kitchen environment, with a non-working handwashing sink and a dirty floor under the dishwasher. The cleaning schedule was not followed, and the dishwasher did not consistently reach the required sanitization temperatures. Staff were aware of these issues, but they persisted, posing a risk of contamination.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility failed to monitor temperatures for six refrigerator/freezers storing food for resident use, with internal temperatures often exceeding the recommended 40 degrees Fahrenheit. Additionally, a cook did not perform proper hand hygiene after handling raw hamburger patties, and had not completed the required Serve Safe certification. These actions were not in compliance with the facility's policy and the 2022 FDA Food Code.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility failed to submit direct care staffing information on schedule for two of four quarterly periods. The PBJ review showed missing data for the 1st and 3rd quarters, which was confirmed by interviews with payroll management and the administrator.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility failed to ensure a sanitary environment in the kitchen, with multiple deficiencies in monitoring and documenting the temperature and sanitizer concentration of the dishwashing machine, as well as the temperatures of the walk-in cooler, walk-in freezer, and reach-in cooler. Numerous instances of missing documentation and non-compliance with facility policies and the 2022 FDA Food Code were observed.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility's main kitchen had sanitation and food storage deficiencies. An unsecured plastic piece and white powdery substance on the ice machine posed contamination risks. The walk-in refrigerator contained improperly labeled and expired food items, which were still available for resident consumption. The dietary manager confirmed the issues but was unsure of the ice machine's cleaning schedule.

Fine: $29,055

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility's main kitchen was inadequately staffed, resulting in late and cold meals, poor food quality, and dissatisfaction among residents. Observations and interviews revealed consistent delays in meal service, with meals often being served cold or improperly cooked. The dietary department faced significant staff turnover and was still training new staff, contributing to the ongoing issues.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.