Every finding on record at South Lincoln Nursing Center

Based on medical record review, staff and resident interview, and policy and procedure review, the facility failed to initiate an investigation following an injury of unknown source for 2 of 2 residents (#1, #2) reviewed for unexplained injuries. The census was 16. The findings were: 1. Review of the 12/8/25 quarterly MDS assessment showed resident #1 had a BIMS score of 12 out of 15 (mild cognitive impairment); weighed 232 pounds; had not had any falls since the last assessment; required substantial/maximal assistance from staff for the mobility activities of daily living of rolling left and right, sitting to lying, lying to sitting on the side of the bed, sitting to standing, and transfers from a chair/bed-to a chair. The resident was totally dependent on staff for toilet transfers. The following concerns were identified: a. Review of RN #1's progress notes on 12/4/25 showed the following: i. At 0407 (4:07 AM) this RN was in another resident's room when the CNA on shift came to this RN and stated I think you should come take a look at [resident room number], [s/he] is complaining of pain on the left side of [his/her] chest and screamed out when I rolled [him/her] to change [his/her] brief. ii. A 4:10 AM progress note showed the resident rated his/her pain at an 8 out of 10 and the pain was sharp. The resident explained to the RN that s/he was getting up yesterday morning and that is when it started hurting, noting that it hurt when [s/he] got up in the sit-to-stand. iii. A 4:27 AM progress note showed the on-call provider was called and informed of the resident status, and the resident said the pain was sharp .but that resident was in pain at this time without any activity and that resident screamed when changed this morning and that this did not occur when changed earlier in the night. iv. A 4:55 AM progress note showed the resident was transferred to the emergency department for an evaluation. v. A 6:34 AM progress note showed the nurse had received a report from the emergency department, the resident had been diagnosed with a chest wall contusion, and had been prescribed Lortab (hydrocodone/acetaminophen) for pain management. b. Review of the emergency department evaluation showed the resident .presents to the emergency department with left-sided chest wall pain that began after an aide rolled him 3 days ago. The patient requires almost 100% assistance to move. [The resident] localizes the pain just below [his/her] left breast. [The resident] states the pain is worse with changing positions or using [his/her] left arm or pushing on this region even taking in a big breath can make it worse. It is most painful when [s/he] is being moved . The emergency department note showed Patient was given a Lortab 5 mg pain medication. [His/her] pain localizes to [his/her] chest wall, reproducible with palpation and use of [his/her] left arm. As [s/he] is difficult to position for X-ray imaging we will do a CT to rule out rib fractures. CT of the chest does demonstrate both evidence for left and right anterior chest wall contusions . c. Review of a 12/5/25 nurse progress note, written by RN #3, showed the resident's representative was upset that staff were transferring [the resident] without the stand-up lift . [the resident's representative] feels like this has contributed to chest pain. In addition, the note showed This RN spoke with [physical therapist] and he reports that he was unable to work with [the resident] today due to him being in a lot of pain, causing difficulty in sitting up so he rescheduled for Tuesday. He will evaluate for safe transfers at that time. Staff instructed to use stand up lift till that time. d. Review of a 12/7/25 nurse progress note, written by RN #2, showed Resident continues to complain of chest wall pain and is utilizing [his/her] PRN (as needed) Hydrocodone 5/325 mg. [The resident] rated it a 6/10 tonight. [The resident complained of [his/her] care and attitudes from staff and called [his/her] daughter. [The resident] reported that [his/her] daughter was coming tomorrow ant that [s/he] was leaving. e. Review of a 12/8/25 progress note, written by RN #2, showed Resident continues to complain of pain and is taking [his/her] Hydrocodone PRN. When assessed the resident [s/he] had no bruising on [his/her] chest currently. [The resident] continues to be concerned about [his/her] care and stated that [s/he] does not want [CNA #2] in [his/her] room period. [The resident] stated that [his/her] daughter has expressed this wish as well. [The resident] stated to this RN that [s/he] is not leaving because [his/her] daughter does not want [him/her] too (sic). Will report to administrative nurses . f. Interview with the resident on 1/6/26 at 8:42 AM revealed s/he sometimes clashes with CNAs but it was taken care of. The resident stated approximately 6 weeks ago a CNA had grabbed him/her around the chest during a transfer and then indicated the area on his/her left upper chest was still sore. The resident was unwilling to share any further information. g. Telephone interview with RN #2 on 1/6/26 at 3:34 PM revealed she had not witnessed any event that led up to resident #1's injury; however, the resident had told her CNA #2 had transferred him/her without using the sit-to-stand lift. RN #1 stated she had emailed the DON and RN #3 to inform them of the allegation. 2. Review of the 12/9/25 quarterly MDS assessment showed resident #2 had a BIMS score of 5 out of 15 (severe cognitive impairment); required substantial/maximal assistance for the mobility activity of rolling left and right and was totally dependent on staff for sitting to lying; chair/bed-to-chair transfers, toilet transfers and tub/shower transfers. The following concerns were identified: a. Review of 12/29/25 nurse progress note, written by RN #2, showed It was reported to this RN that resident had some bruising around [his/her] anus. This RN assessed and found that there is bruising around [his/her] anus. The bruising is red/purple in color. b. Review of a 12/30/25 nurse progress note, written by RN #2, showed Resident is alert and oriented to person and place. [S/he] has a hard time remembering staff names but not faces. [S/he] is transferred via Hoyer. [S/he] is mobile via staff in a wheelchair. [S/he] does have some bruising around [his/her] anus that is going away. 3. Review of the facility documentation showed no evidence the injuries of unknown source had been investigated. 4. Interview with the chief compliance officer on 1/6/26 at 2:34 PM revealed he had consulted the safety officer and an occurrence report related to resident #1 had not been received. 5. Interview with RN #3 on 1/6/26 at 2:45 PM revealed the facility did not track injuries of unknown origin. 6. Interview with the DON on 1/6/26 at 4:05 PM revealed the facility's policy had not been followed and occurrence reports had not been filed related to the injuries of unknown source. 7. Review of the Abuse Prohibition policy, provided by the chief compliance officer, showed Investigation 1. Immediacy: Alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of patient/resident property, will be investigated immediately.

Based on review of medical records, staff interview, policy and procedure review, and review of the State Survey Agency incident database, the facility failed to ensure injuries of unknown source were reported to the State Agency within the required timeframe for 2 of 2 residents (#1, #2) reviewed for unexplained injuries. The census was 16. The findings were: 1. Review of the facility's policy Abuse Prohibition, last reviewed December 2019, showed Reporting/Response 1. General Guidance: Alleged violations, including injuries of unknown source, will be reported immediately to the Administrator or designee and the investigative Task Force which consist of the Administrator, Risk Manager, Compliance Officer, and the immediate supervisor of the employee being investigated. Corrective action will be taken depending on the results of the investigation. 2. Time frames: Alleged violations will be reported to the Office of Healthcare Licensing and Surveys and the Department of Family Services within 24 (twenty-four) hours of the allegation. All allegations of abuse will be reported and the results of the investigation will be reported to the appropriate agencies within 5 (five) working days of the incident. The following concerns were identified: a. Review of a 12/4/25 nurse progress note for resident #1 showed the following:i. At 0407 (4:07 AM) this RN was in another resident's room when the CNA on shift came to this RN and stated I think you should come take a look at [resident room number], [s/he] is complaining of pain on the left side of [his/her] chest and screamed out when I rolled [him/her] to change [his/her] brief.ii. A 4:10 AM progress note showed the resident rated his/her pain at an 8 out of 10 and the pain was sharp. The resident explained to the RN that s/he was getting up yesterday morning and that is when it started hurting, noting that it hurt when [s/he] got up in the sit-to-stand. iii. A 4:27 AM progress note showed the on-call provider was called and informed of the resident status, and the resident said the pain was sharp .but that resident was in pain at this time without any activity and that resident screamed when changed this morning and that this did not occur when changed earlier in the night.iv. A 4:55 AM progress note showed the resident was transferred to the emergency department for an evaluation.v. A 6:34 AM progress note showed the nurse had received a report from the emergency department, had been diagnosed with a chest wall contusion, and had been prescribed Lortab (hydrocodone/acetaminophen) for pain management. b. Review of a 12/29/25 nurse progress note for resident #2 showed It was reported to this RN that resident had some bruising around [his/her] anus. This RN assessed and found that there is bruising around [his/her] anus. The bruising is red/purple in color. 2. Review of the State Agency incident database showed no incidents had been reported since 4/26/25. 3. Interview with the DON on 1/6/26 at 4:05 PM revealed the facility's policy had not been followed and confirmed no incidents had been reported to the state agency since April of 2025.

Based on staff interview, review of the facility change in personnel form, and review of Wyoming's active nursing home administrator's licenses, the Governing Body failed to employ a qualified nursing home administrator. The census was 18. The findings were:1. Review of the state survey agency Healthcare Facility Change in Personnel/E-mail Address Form showed the previous administrator was being changed to the Director of Quality and Compliance and a new administrator was named. The change was indicated as effective 6/16/25. 2. Review of the Wyoming State Board of Nursing Home Administrators Active Roster last updated on 7/14/25 showed the facility administrator did not hold an active license or an active provisional license.3. Interview with the facility administrator on 7/7/25 at 3:52 PM revealed the administrator was the CEO of the facility and confirmed he did not hold an active nursing home administrator's license.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure proper infection control practices for 1 of 2 sample residents (#15) reviewed for urinary catheters or urinary tract infections and during 1 of 1 meal observation. The census was 18. The findings were:Regarding perineal care:1. Observation on 7/9/25 at 11:09 AM showed CNA #3 and CNA #4 entered the room of resident #15 and provided perineal care to the resident. During the observation, CNA #4 assisted the resident to roll towards her. While wearing gloves, CNA #3 removed the resident's brief. At that time, the resident was to noted to have been incontinent of feces and urine and had open areas on his/her buttocks. CNA #3 performed perineal care to remove the urine and feces. Without removing the contaminated gloves, the CNA applied a barrier cream to the resident's buttocks and open areas, assisted the resident with positioning by touching the resident's side and arms, and adjusted the residents clothing and bed linens. 2. Interview with the infection preventionist on 7/10/25 at 9:06 AM revealed staff were expected to remove soiled gloves after providing perineal care, before touching other surfaces, to prevent cross contamination. Regarding meal services:1. Observation on 7/7/25 at 6:07 PM showed CNA #5 applied gloves and began preparing and serving resident meal trays. During the observation, the CNA touched the residents' arms, shoulders, wheelchair handles, and wheelchair wheels and then was observed touching the rims of resident drinking glasses. Observation on 7/7/25 at 6:14 PM showed the CNA touched the wheelchair arm rest and wheel of resident #5 then used a spoon to assist resident #18 to eat. Continued observation showed the CNA sat behind the assisted table, to assist resident #5, #16, and #18, by providing a bite to one resident and alternating to another using the same hand. Observation showed CNA #5 used her gloved hand to remove resident #16's bread, remove bacon from his/her sandwich, and return the bread to the sandwich. The CNA then placed a gloved hand on top of the sandwich, cut the sandwich, and handed a smaller portion to the resident to eat. No glove changes or hand hygiene were performed during the observation.2. Interview with the infection preventionist on 7/10/25 at 9:06 AM revealed that the staff had been asked not to wear gloves during dining services. Further interview revealed staff were to use hand hygiene after touching objects and before touching meal trays and staff should never touch resident's food. The Infection preventionist revealed if there was a problem with the meal, it should be sent back to dietary to correct the issue.3. Review of the policy titled Hand Hygiene provided by the facility on 7/10/25 showed . Hand Hygiene . At all other times, staff will be expected to use alcohol-based hand sanitizer. This should be used when entering resident rooms, prior to providing care to a resident, before and after donning and doffing gloves, when leaving resident rooms, prior to handling food or trays, etc .

Based on observation, resident and staff interview, medical record review, and policy and procedure review, the facility failed to ensure individual activities of preference were provided to 4 of 4 sample residents (#1, #5, #7, #18) reviewed for activities. The findings were: 1. Interview with 8 residents during resident council on 7/8/25 at 2:08 PM revealed the facility had not had any activities for at least 2 weeks and they felt there should be at least a daily activities.2. Review of the quarterly MDS assessment dated [DATE] showed resident #5 had a BIMS score of 9 out 15, which indicate moderate cognitive impairment, and diagnoses which included anxiety disorder, non-Alzheimer's dementia, and depression. Review of the annual MDS assessment dated [DATE] showed the resident indicated it was very important to listen to music, keep up with the news, do his/her favorite activity, and go outside to get fresh air when weather was good. Further review showed it was somewhat important to have books, newspapers, and magazines to read, be around animals such as pets, and do things in groups of people. The following concerns were identified:a. Observation on 7/7/25 at 4:29 PM showed the resident was in his/her room, seated in a recliner making moaning noises and watching television. Observation on 7/8/25 at 8:58 AM showed the resident was in his her room, seated in a recliner making moaning noises and watching television. Observation on 7/9/25 at 1:57 PM showed a balloon hit activity was performed in the common area; however, the resident was not offered or assisted to attend.b. Review of the activity participation from 6/1/25 through 7/9/25 showed there were no activities from 6/18/25 to 7/8/25. The resident was marked active participation for in room visit, movies/television, and talking/conversing on 7/9/25 and was marked as passive participation for exercise on 7/9/25 with a note which said [s/he] wheeled [him/herself out to lunch. All other activities on 7/8/25 and 7/9/25 were marked as not paying attention/sleeping. c. Interview with the activities director on 7/10/25 at 8:54 AM revealed resident #5 did not participate in many activities. The activity director revealed the resident liked music and she tried tried to take him/her for a walks; however, s/he wanted to be in his/her recliner. 3. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had a BIMS score of 14 out 15, which indicated the resident was cognitively intact, and had diagnoses which included anxiety disorder and depression. Review of the annual MDS assessment dated [DATE] showed the resident indicated it was very important to be around pets and animals, keep up with the news, do things with groups of people, do his/her favorite activities, go outside to get fresh air when the weather was good, and participate in religious services and practices. Further review showed the resident indicated it was somewhat important to listen to music s/he liked. The following concerns were identified:a. Review of the activity participation from 6/10/25 through 7/8/25 showed there were no activities from 6/18/25 to 6/23/25 and no activities between 6/25/25 and 7/8/25. 4. Review of the annual MDS assessment dated [DATE] showed resident #7 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included depression. Further review showed the resident indicated it was very important to listen to music s/he liked, to be around pets and animals, keep up with the news, do things with groups of people, go outside to get fresh air when the weather was good, and participate in religious services and practices. Further review showed the resident indicated it was somewhat important to do his/her favorite activities. The following concerns were identified:a. Review of the activity participation from 6/1/25 through 7/9/25 showed there were no activities from 6/18/25 to 7/8/25. 5. Review of the admission MDS assessment dated [DATE] showed resident #18 had short-term and long-term memory impairment and diagnoses which included Alzheimer's disease and non-Alzheimer's dementia. Further review showed the resident indicated it was somewhat important go outside to get fresh air when the weather was good and participate in religious services and practices. The following concerns were identified:a. Review of the activity participation from 6/1/25 through 7/9/25 showed there were no activities from 6/18/25 to 7/8/25.6. Review of the June 2025 activity calendar showed 34 activities which were scheduled from 6/19/25 and 6/30/25. Review of the July 2025 activity calendar showed there were 25 activities scheduled from 7/1/25 to 7/10/25 which included 12 activities scheduled during the survey. Observations during the survey from 7/7/25 through 7/1025 showed only 2 activities were performed which included manicures for residents in the common area on 7/8/25 and noodle ball on 7/9/25.7. Interview with the activities director on 7/10/25 at 8:54 AM revealed in addition to performing activities, she was also working the floor as a CNA. She revealed she was not able to perform daily activities and confirmed the activity schedule had not been followed during the survey. She revealed she was working two days per week on the floor as a CNA and she did not work on the weekends.8. Review of the policy titled Resident Activities provided by the facility on 7/10/25 showed .C. A monthly schedule of planned activities will be posted in each resident's room. These activities will be offered daily .

Based on resident and staff interview, the facility failed to ensure the activities program was directed by a qualified professional. The census was 18. The findings were:1. Interview with 8 residents during resident council on 7/8/25 at 2:08 PM revealed activities had not been performed for at least 2 weeks and the activity director was being pulled to cover as a CNA. Further interview revealed the residents felt there should be daily activities.2. Interview with the activities director on 7/9/25 at 2:55 PM confirmed she was a CNA and did not have a background in recreation or activities. Further interview revealed she was taking an activities class at that time. 3. Interview with the activities director on 7/10/25 at 8:54 AM revealed she was not able to perform activities daily and she did work the floor as a CNA.

Based on medical record review, staff interview, and policy procedure review, the facility failed to ensure residents' right to elect a cardiopulmonary resuscitation (CPR) status for 2 of 12 sample residents reviewed (#16, #18) for advance directives. The findings were: 1. Review of the medical record for resident #16 showed there was no evidence the resident had made an election for CPR status. Review of the electronic health record showed the resident was indicated as do not resuscitate (DNR). 2. Interview with the quality assurance manager on [DATE] at 11:49 AM confirmed there was no evidence resident #16 had elected a DNR status.3. Review of the medical record for resident #18 showed no evidence the resident had made an election for CPR status. Further review showed a WyoPOLST dated [DATE] which indicated comfort focused therapy; however, the CPR and DNR boxes were left blank. Review of the electronic health record showed the resident was indicated as DNR.4. Interview with the DON [DATE] at 11:40 AM revealed residents or the representative showed elect to be full code or DNR at the time of admission. She revealed the representative for resident #18 had indicated the resident was to be DNR; however, she confirmed the WyoPOLST should be completed. Further interview revealed if an election was not made, the resident would be considered full code and she confirmed resident #16 should be a full code. 5. Review of the facility policy titled Advanced Directives provided by the facility on [DATE] showed .4. All residents will be provided a copy of the Wyoming POLST form at the time of admission. The DON and nursing center staff will work with the resident and/or their representative as well as their provider to ensure completion of this form .

Based on medical record review, resident and staff interview, facility incident review, and policy and procedure review, the facility failed to protect the resident's right to be free from verbal abuse by a staff member for 1 of 2 sample residents (#2) reviewed with allegations of abuse. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #2 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included multiple sclerosis, depression, and manic depression. Further review showed the resident had upper and lower impairment bilaterally and required supervision and touching/steadying with eating. The following concerns were identified:a. Review of an incident report dated 4/18/24 showed the resident reported, on 4/7/24, CNA #1 was assisting the resident with eating when CNA #2 stated What, are you going to feed [him/her] like the fucking baby [s/he] is? Further review showed CNA #2 was placed on suspension and an investigation was initiated. The facility incident indicated CNA #2 was interviewed and denied using the f word and referring to the resident as a baby; however, the CNA admitted to asking the CNA #1 Are you really going to feed [him/her]? [S/he] can feed himself. The incident report showed during the interview CNA #2 stated she refused to treat the resident different than other residents and she stated I will not take care of [his/her] clothes for [him/her]. That's not my job. [His/her] family can do that for [him/her]. I will not go in to [sic] [his/her] room at 3:00 AM to change the channel for [him/her] because [his/her] hands are under the blanket and [s/he] doesn't want to reach for the remote. [S/He] can do that for [him/herself]. If [s/he] wants to be fed, [s/he] can go out to the dining room to be fed. [S/He] can do these things on [his/her] own/ I'm not going to do special things for [him/her]. I'm too busy. The CNA then stated I hope you realize what you're doing to my team. I'm scheduled to work the next nine days. Review of the facility incident report showed during an interview with CNA #1, the CNA reported the resident rang for a snack and requested to be fed pudding. CNA #1 explained when pudding was placed in a bowl or on a plate, it made a mess on the resident's bedding so she agreed to feed the resident. CNA #1 reported when she began assisting the resident, CNA #2 was on the other side of the resident's bed and said Are you seriously going to fucking feed [him/her] like a baby? CNA #1 replied to CNA #2 by saying Yes, that is what [s/he] has asked and what is easiest for [him/her]. CNA #1 reported at that time, CNA #2 began yelling and saying things like You're too accommodating for [him/her]. You're making day shift look bad. You treat him like a [king/queen].b. Interview with CNA #2 on 7/10/25 at 8:29 AM confirmed she was suspended and terminated related to resident #2 alleging she him/her a fucking baby; however, the CNA denied the allegation. The CNA revealed she questioned another CNA for assisting the resident with eating instead of the resident eating independently. Further interview revealed the CNA had previous issues with the resident and the resident had allegedly reported other staff members.c. An attempt was made to interview CNA #1 on 7/9/25 at 5:42 PM; however, the phone number was disconnected and the staff member was no longer employed at the facility. d. Interview with resident #2 on 7/10/25 at 9:50 AM revealed s/he had only experienced problems with 1 staff member, which was CNA #2. The resident revealed on one occasion during the graveyard shift, a staff member was giving him/her pudding and CNA #2 stated What are going to do, spoon feed him like a big fucking baby? The resident revealed the comment really upset him/her and made him/her mad. The resident revealed s/he remained mad until s/he learned the CNA was no longer working at the facility.2. Review of the facility policy titled Abuse, Neglect, and Exploitation of Residents & Property approved on 1/30/24 showed .Our residents have the right to be free from abuse, neglect, misappropriation of property and exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat a resident's symptoms .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure as needed (PRN) psychotropic medications were limited to 14 days or there was a documented rationale for 1 of 5 sample residents (#18) reviewed for unnecessary medications. The findings were:1. Review of the admission MDS assessment dated [DATE] showed resident #18 had short-term and long-term memory problems and diagnoses which included Alzheimer's disease and non-Alzheimer's dementia. Further review showed the resident was taking antipsychotic, antianxiety, and antidepressant medications. The following concerns were identified:a. Review of the resident's physician orders showed the resident received lorazepam (antianxiety) 2 mg (milligrams)/1 ml (milliliter) solution 0.25-1 ml by mouth for anxiety every 4 hours as needed and haloperidol (anti-psychotic) 2 mg/1 ml solution 1 ml PRN by mouth every 4 hours for anxiety which were ordered on 5/22/25. Further review showed neither medication had a stop date indicated. Review of the medical record showed no evidence the physician had provided a rationale for the medications to be given as needed for longer than 14 days or evidence of a duration of the medications. b. Interview with the DON on 7/10/25 at 11:42 AM revealed she was not aware of a stop date policy for psychotropic medications. Further interview revealed she had requested a rationale from the physician; however, the facility had not received the rationale.2. Review of the facility policy titled Psychotropic Medications last revised on 6/1/22 showed .4. For PRN orders for psychotropic drugs, the order is limited to 14 days, unless the provider provides documentation of medical necessity beyond 14 days with an updated duration for the order. 5. Anti-psychotic medications PRN orders may not be extended beyond 14 days unless the provider evaluates the resident every 14 days to review necessity for the medications .

Based on resident and staff interview, the facility failed to ensure mail was delivered to residents, including on Saturday. The census was 18. The findings were: 1. Interview with 8 residents during resident council on 7/8/25 at 2:08 PM revealed purchasing and receiving received all mail and was closed on the weekends. The residents revealed the closure of purchasing and receiving resulted in mail delivery not being performed on Saturdays. 2. Interview with quality assurance manager on 7/10/25 at 9:59 AM confirmed mail was not delivered on Saturdays because the facility did not have anyone available to receive it from the post office. Further interview revealed the post office added all mail received on the weekends to a box of mail which was delivered the following Monday.

Based on employee file review, staff interview, abuse registry review, and policy and procedure review, the facility failed to ensure abuse registry verification for 1 of 3 sample CNAs #3 prior to resident contact. The census was 18. The findings were:1. Review of the employee file for CNA #3 showed the CNA had an active license and had a start date of 2/10/25. Further review showed no evidence the CNA abuse registry was checked prior to resident contact. Review of the Wyoming CNA registry at that time showed no evidence the CNA had been added to the registry for verification.2. Interview with the human resources business partner on 7/10/25 at 11:04 AM confirmed there was no evidence of abuse registry verification for the CNA.3. Review of the facility policy titled Abuse Prohibition last reviewed December 2019 showed .Screening 1. Initial: The Human Resources Department will screen potential employees for a history of abuse, neglect, or mistreating patients/residents by : attempting to obtain information from previous employers and/or current employers; checking with the appropriate licensing boards; checking with the appropriate registries, including legal background check .

Based on observation, staff interview, review of the dishwasher and refrigerator/freezer temperature log sheets, manufacturer's instructions, the dietitian site visit reports, hot and cold food temperature logs, and the 2022 FDA Food Code, the facility failed to ensure a sanitary environment in 1 of 1 kitchen. The census was 17. The findings were: Related to temperature monitoring of food storage units: 1. Review of the February and March 2024 temperature log sheets for food storage for the reach-in refrigerator, reach-in freezer, walk-in refrigerator and walk-in freezer showed the temperature of each unit was to be documented twice a day. The following concerns were identified: a. The temperature ranges of each storage unit was not defined on the log sheets. b. No temperatures were recorded on 2/6, 2/11, 2/12, 2/18, 2/23, 2/24, 2/25, 2/26, 3/2, 3/8, and 3/9. c. No evening temperatures were recorded on 2/5, 2/10, 2/16, 2/19, 2/22, 2/27, 3/3, 3/12, 3/19, and 3/20. d. No morning temperatures were recorded on 2/29, 3/1, 3/10, 3/11, 3/16, and 3/17. e. The evening temperature of the walk-in freezer was documented as being 36 degrees Fahrenheit on 2/17 without any corrective action noted. 2. Observation on 3/25/24 at 4:15 PM of the refrigerator/freezer located in the dining room contained snacks for resident consumption. The freezer contained 6 individual cartons of sherbet. The following concerns were identified: a. The temperature range of the refrigerator/freezer was not defined on the log sheet. b. Review of the February and March 2024 temperature log sheet failed to show the temperature of the freezer had been monitored. 3. According to the 2022 FDA Food Code 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: .or (2) At 5 C (41 F) or less. Related to the sanitary environment of the kitchen: 1. Observation on 3/25/24 at 4:15 PM showed the facility used a [NAME] high-temperature dishwashing machine. Review of the Dishmachine Temperature Log showed the minimum temperature of the wash water should be 150 degrees Fahrenheit and the minimum temperature of the rinse water should be 180 degrees Fahrenheit. The temperatures were to be monitored at breakfast, lunch, and dinner. The log sheet also showed a column to record the quaternary solution used for sanitation which required a reading of 400 parts per million (PPM). The following concerns were identified: a. Review of the February 2024 log sheet showed the temperature of the wash and rinse water was not checked 23 out of 87 opportunities. The temperature of the wash water was documented as being below 150 degrees Fahrenheit on 14 days and the temperature of the rinse water was documented as being below 180 degrees Fahrenheit on 6 days with no noted corrective action taken. b. Review of the March 2024 log sheet showed the temperature of the wash and rinse water was not checked 14 out of 76 opportunities. The temperature of the wash water was documented as being below 150 degrees Fahrenheit on 19 days and the temperature of the rinse water was documented as being below 180 degrees Fahrenheit on 3 days with no noted corrective action taken. 2. Interview with the dietary manager on 3/27/24 at 9:19 AM revealed the kitchen did not use a quaternary compound for sanitizing and instead used a solution of bleach and water. The dietary manager stated 3 gallons of water and 3 capfuls of bleach were placed in a sink; using their best judgement as to the amount of water. Further, the dietary manager stated the concentration of the sanitizing solution was not tested after it was prepared and it was drained and replaced every four hours; however, there was no documentation to show the task was completed. Observation of the testing strips, located in a drawer near the sink, showed they could be used up to 200 PPM; however, there was not an expiration date on the vials. 3. Observation on 3/27/24 at 11:28 AM showed cook #1 was assisting with the preparation of the noon meal. The cook was not wearing a beard restraint over his facial hair. Interview with the cook at 12:01 PM revealed he had been educated to keep his beard trimmed to 1/8 to 1/4 inch; however, he had not anticipated being called into work and had not trimmed his beard prior to coming to the facility. 4. Observation on 3/25/24 at 4:15 PM and again on 3/27/24 at 9:05 AM showed the following concerns related to the cleanliness of the kitchen: a. The back splash behind the convection oven, griddle, and stove top were covered in grease which extended to the bottom edges of the upper vents. b. The outside of the General Electric microwave was greasy to the touch and the inside glass tray was covered in dried food debris. c. The base and back of the Kitchen Aide stand mixer was covered with dried food debris and the top was caked with what appeared to be dried yellow batter. d. The bottom of the True reach-in freezer was covered with a dried pink substance and food crumbs. e. The fans in the walk-in freezer were covered in dirt and debris. f. The recipe books, which were stored by the microwave, were greasy to the touch. g. The spice containers located on a shelf below the pot and utensil rack were greasy to the touch and the tops were covered in dust. The lemon-pepper seasoning salt container had a blob of orange colored food debris on the front of the bottle. h. The wall by the steam table and the wall behind the blender and Robot Coupe were splattered with dried food debris. 5. Interview with dietary manager on 3/27/24 at 9:05 AM confirmed the kitchen was dirty and required cleaning. Further, the dietary manager stated she had not established a cleaning schedule. 6. Review of the 3/21/24 dietitian site visit showed the following ongoing issues needed improvement: a. The freezer needed to be clean, frost free, and no food on the floor. b. Food needed to be covered, labeled, and dated. c. The refrigerator and freezer floor needed cleaned. d. The microwave needed cleaned. e. The work tables required cleaning. f. The oven, stove, griddle, and fryer required cleaning. 7. Observation on 3/27/24 at 9:13 AM showed dietary aide #1 had donned gloves and was preparing afternoon and evening snacks for the residents. With the same gloved hands dietary aide #1 entered the walk-in refrigerator, retrieved an apple, and using his fingers held the apple while slicing the apple and placing it in a bowl. At 9:35 AM dietary aide #1 removed his gloves and without performing hand hygiene donned new gloves, entered the dry-storage room, retrieved a small paper plate and labeled it with the date and who the food was for. Using the same gloved hands dietary aide #1 retrieved some sliced bread, placed the bread on the plates, entered the walk-in refrigerator, retrieved some cheese and placed slices of the cheese on the bread. The dietary aide again entered the walk-in refrigerator and retrieved a package of roast beef, opened the bag with a knife, and using the same gloved hands placed the meat onto the sandwich. 8. Interview on 3/27/24 at 1:30 PM with the DON, dietary manager, and the director of quality and compliance officer revealed kitchen staff should change their gloves between tasks; however, the dietary manager stated she did not require hand hygiene to be performed after doffing gloves. 9. Interview with the dietitian on 3/28/24 at 9:44 AM confirmed the kitchen required cleaning and she had noted her concerns on the audit sheets she completed on her site visits twice a month. 10. Review of the 2022 FDA Food Code showed 2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. 11. Review of the 2022 FDA Food Code showed 4-703.11 Hot Water and Chemical. Efficacious sanitization depends on warewashing being conducted within certain parameters. Time is a parameter applicable to both chemical and hot water sanitization. The time hot water or chemicals contact utensils or food-contact surfaces must be sufficient to destroy pathogens that may remain on surfaces after cleaning. Other parameters, such as rinse pressure, temperature, and chemical concentration are used in combination with time to achieve sanitization. When surface temperatures of utensils passing through warewashing machines using hot water for sanitizing do not reach the required 71 C (160 F), it is important to understand the factors affecting the decreased surface temperature. A comparison should be made between the machine manufacturer's operating instructions and the machine's actual wash and rinse temperatures and final rinse pressure. The actual temperatures and rinse pressure should be consistent with the machine manufacturer's operating instructions and within limits specified in SS 4-501.112 and 4-501.113. If either the temperature or pressure of the final rinse spray is higher than the specified upper limit, spray droplets may disperse and begin to vaporize resulting in less heat delivery to utensil surfaces. Temperatures below the specified limit will not convey the needed heat to surfaces. Pressures below the specified limit will result in incomplete coverage of the heat-conveying sanitizing rinse across utensil surfaces. 12. Review of the 2022 FDA Food Code showed 403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. 13. Review of the 2022 FDA Food Code showed 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization - Temperature, pH, Concentration, and Hardness. A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under S7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions .

Based on staff interview and personnel file review, the facility failed to ensure qualifications for the dietary manager were met. The census was 17. The findings were: 1. Interview with the dietary manager on 3/27/24 at 10:15 AM revealed she had not received any training before being hired as the dietary manager. 2. Review of the dietary manager's personnel record showed she received certification on 6/19/23 as a ServSafe Food Protection Manager; however, this certification had not been approved by CMS. 3. Interview with the human resource business partner on 3/28/24 at 12:29 PM revealed the dietary manager was hired as a food service professional on 9/7/22 and was promoted to supervisor on 1/16/23. 4. On 3/28/24 at 12:28 PM the director of quality and compliance officer acknowledged the ServSafe certification did not meet CMS guidelines.

Based on review of the resident council minutes, resident representative and staff interview, and review of the menu, the facility failed to follow the menu as written. The census was 17. The findings were: 1. Telephone interview with resident #8's representative on 3/26/24 at 3:34 PM revealed the menus were monotonous and everything seemed to either come out of a box or a can. The representative stated that she had attended a resident council meeting and the residents were unhappy about the food. 2. Review of the January, February, and March 2024 resident council minutes showed the following concerns: a. The January minutes showed Kitchen hired new staff-hopefully meals will be better. b. The February minutes showed Meals-Not so good-can't cut meat-too dry. c. The March minutes showed Meals: Still not the best-no flavor .Taco's good but not warm enough and no salsa. 3. Interview with the dietary manager on 3/27/24 at 1:30 PM revealed the dietitian had prepared a five-week menu; however, the facility started the menu over at the beginning of each month so the day of the week would correspond to the first day of the menu cycle. The last days of the prepared menu were not used. The dietary manager stated the cooks were supposed to follow the menu using the bold printed list first, and if the facility did not have the products on hand to prepare that menu, the cook was to select the menu printed in italics. Finally, if the kitchen still did not have the products in stock, the cook was to pick something from the menu on the days that were not used. 4. Review of the 3/1/24 through 3/25/24 showed the following concerns: a. The noon meal served to the residents failed to match the printed menu or the alternate menu as outlined by the dietary manager on 13 of the 25 days reviewed (3/1, 3/2, 3/3, 3/4, 3/13, 3/14, 3/16, 3/17, 3/20, 3/21, 3/22, 3/23, 3/24). b. The evening meal served to the residents failed to match the printed menu or the alternate menu as outlined by the dietary manager on 13 of the 25 days reviewed (3/2, 3/3, 3/6, 3/9, 3/10, 3/13, 3/14, 3/16, 3/17, 3/18, 3/22, 3/24, 3/25). c. Food items on the menu included parsnips, carrots, cauliflower, red cabbage, sweet potatoes, cucumbers, sugar snap peas, pickled beets, coleslaw, and tomatoes which were not included on the menus served to the residents during the month of March. d. Some form of potatoes were served to the residents for the noon meal on 11 out of 25 days and the evening meal on 13 out of 25 days. 5. Interview with the dietary manager on 3/27/24 at 9:05 AM revealed she was aware the cooks were substituting other meals than what was on the menu because they were easier to prepare. 6. Interview with the dietitian on 3/28/24 at 9:44 AM revealed it was her expectation the cooks follow the menu for the noon and evening meals as written, and thought perhaps either the kitchen did not have the right ingredients or they failed to plan ahead of time to cook what was on the menu. The dietitian confirmed a lot of potatoes were served as well as starchy vegetables. Further the dietitian stated it was the dietary manager's responsibility to order the food so the menu could be followed.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure an advanced directive was formulated for 2 of 16 residents (#11, #14) reviewed. The findings were: 1. Review of the electronic medical record (EMR) showed resident #11 was listed as do not resuscitate (DNR). Further review of the medical record showed a WyoPOLST (Providers Orders for Life Sustaining Treatment), dated 1/18/21, which showed DNR with comfort-focused therapy was chosen. However, the form had not been signed by the resident or the resident's representative. 2. Review of the EMR showed resident #14 was listed as DNR. Further review of the medical record showed a WyoPOLST, dated 1/7/24, which showed DNR with selective treatment had been chosen. However, the form had not been signed by the resident's primary health care provider. 3. Interview with the director of quality and compliance officer on 3/26/24 at 4:20 PM confirmed the WyoPOLST form was incomplete. 4. Review of the 10/26/23 policy and procedure titled Clinical Protocol/Procedure Advance Directives showed .4. All residents will be provided a copy of the Wyoming POLST form at time of admission. The DON and nursing center staff will work with the resident and/or their representative as well as their provider to ensure completion of this form. 37603

Based on observation, staff interview, and profession standards review, the facility failed to ensure infection prevention techniques were followed for 3 random staff observations. The census was 17. The findings were: 1. Observation on 3/25/24 at 4:10 PM showed CNA #1 was carrying an unbagged, wadded-up incontinence pad down the hall from a resident's room with his/her bare hands. S/he then put the incontinence pad in the dirty utility room, and directly came out and walked back down the hall. S/he then took a hoyer lift to another resident's room without performing hand hygiene. 2. Observation on 3/25/24 at 4:30 PM showed RN #1 was working with medications and had gloves on. The RN put hand sanitizer on her gloves and scrubbed her hands together. Interview at that time with the nurse revealed it was ok to do that. She then stated she did not need to change her gloves, and that they were then clean. 3. Observation on 3/25/24 at 5:49 PM showed CNA #1 was served dinner to the residents. The CNA doffed her right hand glove and grabbed a food item out of a cabinet and handed it to another staff. She failed to perform hand hygiene prior to donning another glove and continued to cut up food and serve the food to the residents. 4. Interview with the DON on 3/28/24 at 9:33 AM revealed the facility expectations were for staff to perform hand hygiene between glove use, and to wear gloves when handling dirty linen. Further, she stated it was not ok to hand sanitize gloves, rather then doffing and donning new gloves. 5. Review of the website cdc.gov/handhygiene/training/interactEducation access on 4/11/24 showed . Hand hygiene (handwashing with soap and water or use of an alcohol-based hand sanitizer) before and after patient contact and after contact with the immediate patient care environment.Standard Precautions should be used for all patients, all the time. Healthcare personnel practice hand hygiene should be done immediately before touching a patient . Immediately after touching a patient, contaminated items or surfaces, or removing gloves. After removing gloves. After touching items or surfaces in the immediate patient care environment, even if you didn't touch the patient while you were there.

Based on medical record review and staff interview, the facility failed to ensure residents with limited range of motion received the appropriate restorative services to increase range of motion and/or prevent further decline for 1 of 2 residents (#9) reviewed for restorative services. The findings were: 1. Review of the 2/15/24 quarterly MDS assessment showed resident #9 had a primary diagnosis of stroke. Review of the resident's care plan, last revised 2/23/24 showed AROM (active range of motion): [resident] is at risk for not being able to feed himself related to [his/her] history of cerebral infarction as evidenced by decreased ROM (range of motion) and fine motor skills in [his/her] upper extremities. The approaches included the restorative nurse aide (RNA) to assist the resident with 3 sets of 10 repetitions of upper and lower extremity AROM activities for 6 out of 7 days per week. The following concerns were identified: a. Review of the January 2024 restorative aide time tracking sheet showed the resident received AROM services on 1/25, and refused services on 1/15, 1/16, 1/23, 1/28, and 1/31. There was no documentation the resident was offered restorative services on the remaining days the RNA was present in the facility (17 days). b. Review of the February 2024 restorative aide time tracking sheet showed AROM was refused by the resident on 2/8, 2/9, 2/20, 2/21, and 2/22. There was no documentation the resident was offered restorative services on the remaining days the RNA was present in the facility (23 days). c. Review of the 3/1 through 3/27/24 restorative aide time tracking sheet showed the resident received AROM services on 3/27 and refused the service on 3/14. There was no documentation the resident was offered restorative services the remaining 23 days the RNA was present in the facility. 2. Interview with the DON on 3/27/24 at 2:45 PM revealed it was the facility's expectation that all residents be offered restorative services 6 out 7 days per week.

Based on observation, resident interview, staff interview, and complaint log review, the facility failed to ensure procedures were in place for the protection of resident property from loss or theft for 1 of 16 residents reviewed (#4). The findings were: 1. Interview with resident #4 on 3/26/24 at 8:28 AM revealed s/he was missing 6 undergarments and their little mesh bag the undergarments go into to be washed. 2. Review of the 2/27/24 at 4 PM quarterly care conference showed the facility had talked to the daughter related to (r/t) religious undergarments and found 2 in his/her dresser. The facility had looked in laundry without success; it was unknown if the resident was soiling and throwing them away. 3. Observation of laundry services on 3/28/24 at 9:31 AM showed only a pair of socks that were in the unknown resident box. The laundry service employee stated there was 1 mesh bag in the dryer at that time. 4. Interview with the DON on 3/28/24 at 9:33 AM revealed the facility did not track the missing items and show the outcome. She stated prior to this recent loss of belongings, she had searched all the residents' linen and did not find any. She stated she did not document it in the record or concern log. Further, she stated the resident did come and see her last night at 5:30 PM about the missing items. 5. Interview with resident #4 on 3/28/24 at 10:01 AM revealed the 6 religious undergarments have be replaced 3 different times. The resident stated s/he was down to 1 at this time. The resident further stated this was the only concern s/he had with the facility. Additionally, the resident stated s/he spoke to the DON the previous night about the missing items. 6. Review of the grievance/concerns log failed to show the resident had a concern with the missing religious undergarments.

Based on medical record review and staff interview, the facility failed to ensure residents were monitored for side effects of psychotropic medications for 2 of 5 residents (#5, #9) reviewed for unnecessary medications. The findings were: 1. Review of the 3/27/24 quarterly MDS assessment showed resident #5 was admitted to the facility on [DATE] and had diagnoses which included anxiety disorder, depression, and intermittent explosive disorder. Review of the most recent physician orders showed the resident was prescribed fluoxetine HCl (an antidepressant) 20 milligrams (mg) daily on 12/30/19 and Abilify (an antipsychotic) 2.5 mg every other day on 11/5/21. The following concerns were identified: a. Review of the 1/25/24 Physician Rationale for Clinical Contraindication of Gradual Dose Reduction worksheet showed the side effects for fluoxetine HCl were identified as insomnia, fatigue, increased appetite, loss of sexual desire, and nausea. The side effects for Abilify were identified as blurred vision, dry mouth, drowsiness, muscle spasms, weight gain, and involuntary movements. Further review of the resident's medical record showed no evidence a system had been developed to monitor the side effects of each medication. 2. Review of the 2/15/24 quarterly MDS assessment showed resident #9 was admitted to the facility on [DATE] and had a diagnosis of depression. Review of the most recent physician orders showed the resident was prescribed sertraline HCL (an antidepressant) 150 mg daily with a start date of 5/6/19. The following concerns were identified: a. Review of the 1/25/24 Physician Rationale for Clinical Contraindication of Gradual Dose Reduction worksheet showed the side effects for sertraline HCl were identified as insomnia, fatigue, increased appetite, loss of sexual desire, and nausea. Review of the resident's care plan, dated 1/30/23, showed staff should evaluate the effectiveness and side effects of medications for possible need or ability to increase or decrease psychotropic drugs. Further review of the resident's medical record showed no evidence a system had been developed to monitor the side effects of the medication. 3. Interview on 3/27/24 at 4:35 PM with the DON confirmed a system had not been developed to monitor the side effects of the psychoactive medications.

Based on medical record review, staff and resident interviews, and review of personnel files and facility documentation, the facility failed to protect the resident's right to be free from verbal abuse by staff for 1 of 1 sample residents (#1) reviewed for abuse allegations. The findings were: 1. Review of the 2/7/23 quarterly MDS assessment showed resident #1 had diagnoses including cerebrovascular accident, transient ischemic attack or stroke, and depression. The assessment showed the resident had a BIMS score of 2 out of 15, which indicated severe cognitive impairment. The following concerns were identified: a. Review of the facility's Human Resources Fact Finding Summary showed on 3/16/23 CNA #1 reported that on 3/15/23 she heard CNA #2 say to the resident You hit me and I'll be the last person you ever hit. Review of the facility's conclusion of their investigation into the allegation showed [CNA #2] admitted to verbally abusing the patient, losing her temper, and getting a little out of control . The report recommended that the CNA be terminated from employment for violation of the facility's abuse policy. Review of documentation in the personnel file of CNA #2 dated 3/20/23 showed the facility terminated her employment. b. During an interview on 4/10/23 at 2:09 PM CNA #1 stated on 3/15/23 around 8:40 PM to 10 PM she was working with CNA #2 in the resident's room. She stated the resident was frustrated while the CNAs were assisting him/her with cleaning him/her up in bed. She stated she went into the bathroom to get more wipes and heard CNA #2 say to the resident You hit me and I'll be the last person you hit. She stated the CNA did not say it in a joking manner, and she was unsure what the resident's response was because she wasn't looking at the resident. She further stated the resident and CNA #2 bickered back and forth and so she told both of them to calm down .take a breath. She stated after the incident she reported the incident to the charge nurse, RN #1, and then also reported it the following day. c. On 4/10/23 at 3:07 PM the resident was interviewed. He did not recall the incident and had no concerns with staff. d. During a phone interview on 4/10/23 at 3:28 PM RN #1 stated CNA #1 did report to her that CNA #2 told the resident something like don't hit me .I'll be the last person you hit the evening of 3/15/23. e. On 4/10/23 at 3:34 PM CNA #2 was interviewed via phone. She stated on the evening of 3/15/23 she and CNA #1 were assisting the resident in bed. She stated the resident was agitated and was cussed at her. She stated the resident then doubled up his/her fist and started swinging. She stated she told the resident If you hit me, it will be the last time you will hit a woman. She stated she should not have said that and she didn't mean it.