Citations in Wyoming
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Wyoming.
Statistics for Wyoming (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Wyoming
A resident with multiple physical limitations who used an electric wheelchair sustained a fractured leg after getting caught in a doorway and later suffered a large bruise from bumping into a bed. Despite these incidents, no wheelchair safety assessments were completed, and the care plan was not updated with additional interventions. Staff interviews confirmed that safety assessments should have been performed for residents using power wheelchairs.
A resident with severe cognitive impairment and high assistance needs was physically abused by their roommate, who struck them in the head while the resident was seated in a wheelchair. Staff witnessed the incident, and the victim was found with redness on the head and later reported headaches. The two residents had a history of verbal conflict, but the facility failed to prevent the escalation to physical abuse, resulting in actual harm.
The facility did not provide enough nursing staff to meet resident needs, resulting in prolonged call light response times and inadequate care. A resident dependent on staff for transfers was left unable to reach the call light or phone, sometimes sitting in feces due to delays. Multiple residents and staff reported frequent understaffing, with some CNAs responsible for up to 27 residents at night and call lights going unanswered for over an hour. The DON confirmed there was no policy for call light response times and acknowledged ongoing staffing challenges.
Two residents with severe cognitive impairment experienced physical abuse from other residents, including being struck, scratched, and having hair pulled out. Staff witnessed the incidents and intervened, but the affected residents suffered both physical injuries and emotional distress as a result.
A resident with moderate cognitive impairment and mobility needs fell in the bathroom after waiting an extended period for staff assistance, as the emergency call light was not answered for over 30 minutes. The resident sustained a head injury and later died from a subdural hematoma. Staff interviews and records indicated previous delays in call light response, and the call light system did not distinguish between emergency and regular calls, contributing to the delayed response.
A resident with significant medical needs was left shivering and uncomfortable during a dressing change after a shower. Despite the resident expressing that they were cold and a CNA offering to increase the heat, the RN declined the request, prioritizing their own comfort while wearing PPE. The resident later confirmed they would have preferred the heat be turned up during the procedure.
A resident with diagnoses of bipolar disorder, anxiety disorder, and a history of stroke was admitted without a required PASRR Level II evaluation, despite the Level I screening indicating the need for further assessment. Medical record review and staff interview confirmed the evaluation was not completed prior to admission.
A resident with a history of cancer, frequent pain, and recent surgeries was not effectively managed for pain during a dressing change. Despite having orders for pain medication and an established acceptable pain level, the RN did not assess or address the resident's pain before or during the procedure, only providing pain relief after the resident reported severe discomfort. Staff interviews indicated inconsistent premedication practices, and the resident confirmed experiencing pain and a preference for premedication prior to such procedures.
A staff member was observed carrying unbagged soiled towels in ungloved hands through the rehabilitation hall to the soiled linen room, contrary to facility policy and CDC standards requiring soiled linen to be bagged before transport.
Two residents, both cognitively intact but with mobility limitations, were involved in a physical altercation in their shared room, resulting in injuries including a swollen jaw, hematoma, head abrasion, and a fractured hand. The incident was preceded by reports of fear and prior aggression, and staff responded to a commotion, finding one resident on the floor and both holding a walker. Both residents required hospital evaluation, and one was later transferred due to a blood infection and subsequently passed away.
Failure to Assess and Address Wheelchair Safety After Resident Injuries
Penalty
Summary
The facility failed to evaluate and address hazards and risks for a resident who was cognitively intact but had significant physical limitations, including diabetes mellitus, morbid obesity, muscle weakness, and gout. The resident required the use of an electric wheelchair for mobility. Despite these risk factors, the facility did not complete a wheelchair skill or safety assessment after the resident sustained a right leg fracture in June, which occurred when the resident's leg became caught in a courtyard doorway while using the wheelchair. Medical documentation confirmed the injury, including an orthopedic note and X-ray results showing an acute, nondisplaced oblique fracture of the distal tibial diaphysis. Additionally, the resident experienced a large bruise to the left calf after bumping into a bed with the wheelchair in October. Interviews with both the resident and the Physical and Occupational Therapy Director confirmed that no wheelchair safety assessments were conducted following either incident. The care plan only included an intervention to educate the resident on proper use of mobility devices, with no further interventions or assessments added after the injuries. An RN confirmed that safety assessments should have been completed for all residents using power wheelchairs.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A resident with severe cognitive impairment and multiple diagnoses, including non-traumatic brain dysfunction and dementia, was subjected to physical abuse by their roommate. The resident required substantial to maximal assistance for mobility and had recently returned to the facility after being away for a few days. The incident occurred when another resident entered the room and was observed by staff hitting the resident in the head while the victim was seated in a wheelchair. The assaulted resident was found to have redness on the head and later complained of intermittent headaches following the incident. Staff interviews and medical record reviews confirmed that the two residents had a history of bickering, but there was no clear indication of what provoked the physical altercation. The staff member who witnessed the event reported hearing yelling and seeing the aggressor striking the resident, while the victim did not verbally respond during the incident. The nurse who assessed the situation noted mild redness to the back of the resident's head and documented that the resident expressed feeling unsafe with the aggressor as a roommate. The facility's policy states that residents will be protected from abuse, neglect, and harm while residing at the facility. Despite this, the resident was not protected from physical abuse by another resident, resulting in actual physical harm. The incident was witnessed by staff, and documentation indicated that the resident felt unsafe following the event.
Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents on three of four units, as evidenced by multiple interviews, grievance and call light log reviews, and direct observations. One resident, who was cognitively intact and dependent for toilet transfers, reported long wait times for call light responses and meals. The resident's representative and roommate confirmed that the resident was sometimes left sitting in feces due to extended wait times, and that the call light and phone were often placed out of reach. Observations confirmed the resident was left unable to access the call light and phone, and grievance logs documented similar concerns from the resident's family. Call light logs showed multiple instances of excessive wait times, including waits of up to 84 minutes. Additional interviews with residents during a council meeting revealed that call lights were often turned off by staff with promises to return, but assistance was not provided in a timely manner. One resident reported waiting 73 minutes for a call light to be answered. Staff interviews confirmed frequent understaffing, with reports of only one CNA on a locked unit and two for the rest of the building at times, resulting in residents being left soaked in the morning. CNAs described situations where one CNA was responsible for up to 27 residents at night, and call lights remained unanswered for over an hour. The DON acknowledged the lack of a facility policy on call light response times and confirmed ongoing issues with staffing and call light response.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, resulting in actual harm to two residents with severe cognitive impairment. In one incident, a resident with Alzheimer's disease and severe cognitive impairment was found outside a staff bathroom, yelling obscenities and accusing another resident of pinching them. The accused resident was found with their hands near the complainant's neck, and staff observed a 0.6 cm open wound on the neck of the resident who reported being pinched. The wound was cleaned and dressed by nursing staff. In another incident, a resident with moderate cognitive impairment and a history of verbal aggression struck a severely cognitively impaired resident in the face with a spiral notebook. The victim was visibly upset and cried, asking why the assault occurred. Approximately 30 minutes later, the same aggressor pulled a clump of hair from the victim's head, requiring intervention by two staff members to separate them. The victim was again distressed and refused further care related to hair grooming for the remainder of the night. Staff interviews confirmed that these incidents were witnessed and that the aggressors were separated from the victims following the events. The facility's policy on abuse, which defines abuse as including physical abuse and mistreatment of vulnerable adults, was reviewed as part of the investigation. The incidents demonstrate a failure to prevent resident-to-resident physical abuse, resulting in physical and emotional harm to the affected residents.
Failure to Provide Adequate Supervision and Timely Call Light Response Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent accidents for a resident with moderate cognitive impairment and progressive neurological conditions. The resident required partial to moderate assistance with mobility and activities of daily living, including transfers and toileting. On the day of the incident, the resident fell in the bathroom after attempting to use the toilet without assistance, resulting in a head injury and an abrasion to the left elbow. The fall was unwitnessed, and the resident was found on the floor by a CNA after the emergency bathroom call light had been activated for an extended period. Medical record review and staff interviews revealed that the resident had previously reported delays in staff response to call lights, sometimes waiting over 20 minutes, which led the resident to attempt bathroom use independently. On the day of the fall, the emergency bathroom call light was activated and remained unanswered for 36 minutes before being cancelled. The CNA who found the resident was unfamiliar with the resident and had been told the resident was fairly independent. The RN who responded noted that the resident did not normally use the call light and that no alarms were heard at the time of the incident. Further investigation showed that the call light system in use at the time did not differentiate between emergency and regular calls, as both had the same tone, making it difficult for staff to prioritize responses. The administrator confirmed that staff were expected to answer call lights immediately, but the system's limitations and staff unfamiliarity contributed to the delayed response. As a result of the fall, the resident developed a subdural hematoma and subsequently passed away.
Resident Choice Not Honored During Dressing Change
Penalty
Summary
A cognitively intact resident with a history of cancer, malnutrition, frequent pain, rheumatoid arthritis, muscle weakness, and recent major surgeries involving nephrostomy tubes and a colostomy, was observed during a dressing change following a shower. The resident was lying in bed with their upper body exposed and was visibly shivering. When the resident verbalized feeling cold, a CNA offered to increase the room temperature, but the RN performing the dressing change declined, stating not to adjust the heat at that time. The RN was wearing PPE and commented on feeling hot and needing a shower after the procedure. The resident later confirmed in an interview that they were cold during the dressing change and would have preferred the heat be increased.
Failure to Complete Required PASRR Level II Evaluation Prior to Admission
Penalty
Summary
A deficiency was identified when a resident was admitted to the facility without completion of a required Level II PASRR (Preadmission Screening and Resident Review) evaluation. The resident, who was cognitively intact with a BIMS score of 13 out of 15, had documented diagnoses including bipolar disorder, anxiety disorder, and a history of cerebrovascular accident, transient ischemic attack, or stroke. Review of the resident's PASRR Level I screening indicated the presence of a mental illness that necessitated a Level II PASRR evaluation prior to admission. However, medical record review and staff interview confirmed that this evaluation was not completed before the resident's admission.
Failure to Provide Effective Pain Management During Dressing Change
Penalty
Summary
A resident with a history of cancer, frequent pain, rheumatoid arthritis, muscle weakness, and recent major surgeries involving nephrostomy tubes and a colostomy was not provided with effective pain management during a dressing change. The resident, who was cognitively intact, had physician orders for acetaminophen and oxycodone for pain, with an acceptable pain level set at 5 out of 10. During an observed dressing change, the resident verbalized significant pain and discomfort, but the RN did not assess or acknowledge the pain prior to or during the procedure. Pain was only assessed after the dressing change, at which point the resident rated the pain as 8 to 9 out of 10 and was then administered acetaminophen per request. Interviews with staff revealed that premedication for pain prior to dressing changes was only done occasionally, and the RN admitted to sometimes proceeding with procedures despite the resident's pain and anxiety. The DON confirmed that premedication was provided only if it was within the physician's ordering timeframe. The resident later confirmed experiencing pain during the dressing change and expressed a preference for premedication prior to such procedures. Facility policy required that residents receive care in accordance with professional standards and their choices related to pain management, including assessment of both verbal and non-verbal indicators of pain.
Failure to Bag Soiled Linen During Transport
Penalty
Summary
During a random observation, an unidentified staff member was seen transporting unbagged soiled towels in her ungloved hands down the rehabilitation hall to the soiled linen room. According to an interview with the infection prevention coordinator, facility protocol requires that soiled linen be bagged before removal from residents' rooms and remain bagged during transport to the laundry room. Review of both the Centers for Disease Control and Prevention standards and the facility's own Infection Prevention and Control Program policy confirmed that soiled laundry should be bagged prior to transport to prevent the spread of infection. The observed staff action did not comply with these established procedures.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Harm
Penalty
Summary
The facility failed to protect residents' right to be free from physical abuse by another resident, resulting in actual harm to two residents. One resident, who was cognitively intact and dependent on staff for transfers, was involved in a physical altercation with a roommate, also cognitively intact but requiring supervision for mobility. The incident occurred in their shared room, where staff responded to a commotion and found one resident on the floor and both holding a walker. Both residents sustained injuries: one had a swollen jaw and a hematoma, while the other had a bleeding head and a fractured hand. Both were sent to the hospital for evaluation and treatment. Prior to the incident, there were indications that one resident was afraid of the other, and it was reported that the aggressive resident had previously attacked another person. The altercation was triggered when a visitor entered the room, and a misunderstanding led to one resident becoming angry and striking the other with a walker. Staff interviews confirmed that the injured resident was found on the ground, screaming for help, while the aggressor was standing over them. Law enforcement was notified, but no immediate threat was determined since the injured resident was transferred out of the facility. Medical records and interviews revealed that the injured resident was later transferred to another facility due to a blood infection affecting the spine and subsequently passed away in the hospital. The aggressive resident admitted to punching the roommate and was later involved in another episode of aggression toward staff. The facility's policy required the prevention of abuse, neglect, and exploitation, but the events leading up to and during the altercation demonstrated a failure to protect residents from physical abuse.
Some of the Latest Corrective Actions taken by Facilities in Wyoming
- CNA #2 was suspended pending an investigation, an abuse allegation investigation was initiated, including resident interviews and reporting to appropriate entities, and education was provided to all staff on abuse reporting and investigation procedures. (K - F0610 - WY)
- Resident assessment was conducted, the involved CNA was suspended, the facility reported the incidents to the adult protection agency, state survey agency, and state board of nursing, and disciplinary action was taken against the perpetrators. (G - F0600 - WY)
- The facility implemented a Quality Assessment and Performance Improvement (QAPI) program addressing resident-to-resident abuse, placed the aggressive resident on increased and then one-to-one observation, provided staff training on behavior management and working with residents exhibiting aggression, and made plans to transfer the aggressive resident to another facility. (G - F0600 - WY)
Failure to Investigate Abuse Allegation and Protect Resident
Penalty
Summary
The facility failed to respond to an allegation of abuse and protect a resident's right to be free from verbal abuse by a staff member. The incident involved a CNA who verbally abused a resident and attempted to physically move the resident against their will. The grievance was reported by another CNA and witnessed by an LPN, but the facility did not take immediate action to investigate or protect the resident. The abusive CNA continued to work multiple shifts following the incident, and the grievance was not logged in the facility's grievance log. Interviews with staff revealed that the incident was reported to the Business Office Manager (BOM), who asked the reporting CNA to document it in writing. Despite this, the grievance was not acted upon promptly, and the abusive CNA remained on duty. The facility's failure to investigate the abuse allegation and protect the resident led to a determination of immediate jeopardy. The facility's policy required immediate reporting and investigation of abuse allegations, which was not followed in this case.
Removal Plan
- CNA #2 was suspended pending an investigation.
- An abuse allegation investigation was started which included resident interviews and reporting of the allegation to the appropriate entities.
- Education was provided to all staff on abuse reporting notification and investigation which included education of oncoming staff before contact with residents.
Failure to Provide CPR According to Advance Directive
Penalty
Summary
The facility failed to provide CPR in accordance with a resident's advance directive, resulting in the resident's death shortly after admission. The resident had signed a POLST indicating a full code status, which was also signed by the physician. However, when the resident became unresponsive and lost signs of life, the staff did not initiate CPR. The administrator and the DON both believed the resident was a DNR/DNI based on information from the hospital and were unaware of the updated POLST. The POLST was not found in the disaster recovery binder at the nurses' station, and there was no documentation of the resident's mottling or physician notification prior to the resident's death. Interviews with various staff members revealed a lack of awareness and communication regarding the resident's code status. The LPN who admitted the resident did not recall the resident's code status, and the social worker confirmed that medical records personnel processed the admission paperwork, including the POLST. The physician who signed the POLST was not notified of any concerns until the resident's death. The facility's policies on code blue and advance directives were not followed, leading to the failure to provide CPR as requested by the resident's advance directive.
Removal Plan
- Education to all staff regarding POLST forms and code blue.
- 100% audit of all POLST forms for all current residents.
- Audit of all licensed nurses for verification of up to date CPR.
- A mock Code Blue drill was conducted and would occur on every shift.
Resident Abuse and Neglect by CNAs
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse, as well as neglect, as evidenced by incidents involving two CNAs. The resident, who had severe cognitive impairment and was dependent on staff for personal care, was left unattended in the bathroom and went unchecked for 13 hours during a CNA's shift. This neglect was captured on audio/video surveillance, and other staff reported concerns about the conditions of residents, such as saturated briefs and beds, and dried feces and urine left on beds. In another incident, the resident's daughter provided video footage showing a CNA verbally and physically abusing the resident. The footage showed the CNA pushing the resident in bed, pulling the resident up by one arm, and using aggressive and threatening body language. The CNA was also observed turning off the resident's call light and refusing to take the resident to the bathroom, leading to the resident expressing fear about calling for help. Interviews revealed that the CNA involved in the physical and verbal abuse had complained about being overwhelmed and needing help. The CNA stated that she had no intention of hurting the resident and was frustrated during the shift. The resident's daughter reported these incidents to the facility, and the resident exhibited new fearful behavior following the incidents.
Removal Plan
- Resident assessment
- CNA suspension
- Facility reported to adult protection agency, state survey agency, and state board of nursing
- Disciplinary action for the perpetrators
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, resulting in harm to two residents. Resident #5, who had moderate cognitive impairment and various medical conditions, was injured in an altercation with resident #1, who also had significant cognitive impairment and other health issues. During the incident, resident #1 entered resident #5's room, became agitated, and pushed resident #5, causing them to fall and sustain a fracture. This incident was documented in an incident report and confirmed through a facility investigation. A subsequent incident involved resident #1 entering the room of resident #2, who had significant cognitive impairment and multiple diagnoses. Resident #1 hit resident #2 on the shoulder, causing slight redness. This altercation occurred during a shift change when resident #1 was unsupervised, despite being on 1:1 observation. The facility's investigation substantiated both incidents, indicating a failure to adequately supervise and protect residents from abuse.
Removal Plan
- Implemented a quality assessment process improvement (QAPI) program addressing resident-to-resident abuse.
- Placed resident #1 on increased observation.
- Provided staff training including behavior management and working with residents with behaviors to decrease the risk of aggression towards other residents.
- Placed resident #1 on 1:1 observation.
- Plans made to transfer resident #1 to another facility.
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