Worland Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Worland Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF689Feb 26, 2026

  Based on observation, staff interview, medical record review, and policy and procedure review, the facility failed to ensure residents received adequate supervision and devices to prevent accidents for 5 of 5 sample residents (#1, #9, #10, #11, #15) reviewed for accident hazards. This failure resulted in actual harm to resident #1 who received burns from hot liquid. The failure resulted in a determination of immediate jeopardy due to a lack of implementation of interventions, including adequate supervision and use of safety equipment. The census was 67. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had a BIMS score of 9, which indicated moderate cognitive impairment, and had diagnoses which included stroke, hemiplegia, and dysphagia. […]

• Actual harm, isolatedF684Jul 7, 2026

  Based on observation, medical record review, staff and resident representative interview, the facility failed to ensure an assessment was performed for 7 of 9 sample residents (#1,#3, #4, #5, #6, #7, #8) reviewed for change of condition. This failure resulted in actual harm to residents #4 and #8 who experienced a delay in treatment. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #4 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included stroke, anemia, hypertension, renal disease, hemiplegia, and seizure disorder. The following concerns were identified:a. Review of a nursing progress note dated 4/30/26 and timed 5:22 PM showed Resident complained of nausea. […]

• Actual harm, isolatedF600Feb 26, 2026

  Based on medical record review, staff interview, review of incident and facility documentation, and policy and procedure review, the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 of 7 sample residents (#2) reviewed for abuse. This failure resulted in actual harm to resident #2. The facility had implemented corrective action prior to the survey and was found to be in substantial compliance as of 9/11/25. The findings were:1. Review of the 11/14/25 quarterly MDS assessment showed resident #2 had severely impaired memory, and had verbal behavioral symptoms directed toward others. Further review showed the resident had a diagnosis of non-Alzheimer's dementia. […]

• Actual harm, isolatedF600Oct 24, 2024

  Based on medical record review, staff interview, review of incident and facility documentation, and policy and procedure review, the facility failed to ensure residents were free from physical abuse by other residents for 1 of 9 sample residents reviewed. This failure resulted in actual harm to resident #1. The findings were: The facility had implemented corrective action prior to the survey and was determined to be in substantial compliance as of 9/27/24. 1. Review of the 10/6/24 admission MDS assessment showed resident #1 (victim) had a BIMS of 3, which indicated severely impaired cognitive skills, and had diagnoses of non-Alzheimer's dementia and pelvic fractures. […]

• Actual harm, isolatedF684May 5, 2023

  Based on medical record review, hospital medical record review, resident representative interview, and staff interview the facility failed to identify and assess for change of condition in accordance with professional standards of practice for 1 of 7 residents (#4) reviewed for possible change of condition assessments. This failure resulted in harm to resident #4, whose signs and symptoms of pneumonia, UTI, heart failure and/or heart attack went unaddressed until family intervention. The findings were: Review of the 12/6/22 admission MDS assessment for resident #4 showed resident had a BIMS score of 14 out of 15, which indicated intact cognitive ability. […]