Every finding on record at Hospice of Laramie

Based on medical record review, staff interview, complaint review, and policy review, the facility failed to ensure the patient's representative was treated with respect, and was free to exercise their rights without fear of reprisal from the hospice for 1 of 5 sample patients (#1). The findings were: --- 1.Review of a spiritual counselor visit note for patient #1 dated 11/24/25 showed "Interventions Performed This Visit, DON [Director of Nursing] called me before this visit with the parents. She told me that she had recommended to {mothers name} to consider retaining a GAL {Guardian Ad Litem} to deal with the co-parenting issues..."  "...Listened as Z shared his resentment, distrust and fear re [sic] triangulations with the fa. [sic] He complained that talk of a GAL is unnecessary. .."  "...I referred him to the {administrators' name}."2. Review of "Complaint Report - Ongoing - 2025" hand delivered by the administrator on 1/7/26 at 11:55 AM included "...Concern 1: He expressed concern that Hospice is getting involved again with the GAL. ...During Patient Debrief Meeting today, {Spiritual Director name} brought up a little bit of this mentioning to stay out of triangulation and {RN (Registered Nurse) #1 name} got very inappropriately defensive on Moms side and made some semi-snide comments regarding dad. So, I would say there are some feelings that {patients' fathers name} is definitely picking up on that we need to pull ourselves away from. Additionally, {patients' fathers' name} has again expressed concerns with not trusting or wanting to work with {DON name} because he is worried that he won't be taken seriously, and the patient will suffer..." Response from the DON included "...Sunday - she again called, {patient fathers name} blocking communication. I said I think {Spiritual Director name} would suggest trying to get a GAL in place for these type of scenarios but up to to her..." 3. Interview with the DON on 1/8/26 at 1:35 PM revealed the GAL was suggested by the spiritual director. "I did not push the GAL, just mentioned what was already offered." "We try to stay out of personal affairs." She stated she was unaware if RN #1 ever got educated related to the favoritism towards the mother. 4. Review of "Patient's Rights and Responsibilities" last reviewed 06/2022 showed "...4.c. to exercise his or her rights as a patient of the hospice without being subjected to discrimination or reprisal for exercising these rights:

Based on medical record review, staff interview, and policy review the facility failed to ensure safety precautions were included on the plan of care (POC) for 3 of 3 patients with home visits (#9, #10, #11). The findings were: --- 1. Review of the POC for patient #9, date of benefits 6/26/25 to 9/23/25, showed a diagnosis of Parkinson's Disease with Dyskinesia. The medications showed the patient was on aspirin and oxygen nasal cannula daily. The following concern were identified:          a. Review of the POC failed to show safety precautions.2. Review of the POC for patient #10, benefit date 5/16/25 to 8/13/25, showed diagnoses of severe protein-calorie malnutrition, paroxysmal atrial fibrillation, abnormal weight loss, and bed confinement status. The medications included aspirin, Ativan (benzodiazepines), citalopram (antidepressant), hyoscyamine sulfate (anticholinergic or antimuscarinic), lorazepam (benzodiazepine), and morphine (opioid).  The following concerns were identified:a. Review of the POC showed the facility failed to showed safety precautions. Interview with Register Nurse (RN) #2 during the home visit on 7/1/25 at 1 PM confirmed staff would not know what precautions were in place for the patient by looking at the POC.3. Review of the POC for patient #11, showed benefit period of 6/26/25 to 9/23/25, diagnoses of severe protein-calorie malnutrition, Alzheimer’s disease, bipolar disorder, and infectious disease. The medications included Ativan (benzodiazepine), lamotrigine (antiepileptic), morphine (opioid), sertraline (SSRI), and oxygen 1 – 5-liter nasal cannula continuous. The following concerns were identified:a. Review of the POC showed the facility failed to show safety precautions.4. Interview with the DON and Administrator on 7/3/25 at 10:32 AM revealed the POC should have the safety precautions listed. 5. Review of policy “Plan of Care” hand delivered on 7/3/25 at 10:07 AM showed “…1. The patient’s plan of care specifies the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive, and updated assessments of the patient. “

Based on observation, medical record review, staff interview, and policy review the facility failed to ensure medical supplies and safety precautions were included on the plan of care (POC) for 3 of 3 patients with home visits (#9, #10, #11). The findings were: --- 1. Review of the POC for patient #9, date of benefits 6/26/25 to 9/23/25, showed diagnosis of Parkinson's Disease with Dyskinesia. The medications showed the patient was on aspirin and oxygen nasal cannula daily. The following concerns were identified:              a. Observation on 7/1/25 at 11 AM during a home visit with patient #9 revealed the patient had 2 urinals, an oxygen concentrator, oxygen tanks, nasal cannula and tubing, a shower chair, wheelchair, lift chair and gait belt. The POC only showed the patient had a “Roller walking with Seat”. 2. Review of the POC for patient #10, benefit date 5/16/25 to 8/13/25, showed diagnoses of severe protein-calorie malnutrition, paroxysmal atrial fibrillation, abnormal weight loss, and bed confinement status. The following concerns were identified:                      a. The POC showed air mattress. However, it failed to show incontinence brief, and wheelchair.               3. Review of the POC for patient #11, benefit period of 6/26/25 to 9/23/25, showed diagnoses included severe protein-calorie malnutrition, Alzheimer’s disease, bipolar disorder, and infectious disease. The following concerns were identified:                a. The POC showed hospital bed and air mattress. Observation on 7/2/25 at 12 PM showed the patient had a 4-wheel walker, electric wheelchair, toilet riser, grip bars, oxygen concentrator, oxygen bottles, oxygen tubing and wore hearing aids.       4. Interview with the DON and Administrator on 7/3/25 at 10:32 AM revealed the POCs should have the DME or supplies listed. 5. Review of policy “Plan of Care” hand delivered on 7/3/25 at 10:07 AM showed “…1. The patient’s plan of care specifies the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive, and updated assessments of the patient. “

Based on document review and staff interview, the facility failed to perform an annual update of the Emergency Preparedness Plan (EPP) as required. Failure to update the EPP as required could result in out-of-date information regarding contacts or procedures, which may result in injury or death in the event of an emergency. The deficiency could impact all staff and residents in the facility. The findings were: --- Document review on 07/01/2025 starting at 1:15 PM revealed that the facility was in the process of updating their emergency preparedness plan, but that updates had not been completed since the time of the last survey performed in 2022.Interview with the facility administrator and facility maintenance manager at the time of the observation acknowledged the deficiency, and indicated that they were aware of the requirement.Interview with the facility administrator at the time of exit confirmed the deficiency.

Based on document review and staff interview, the facility failed to test the fire alarm system in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 72, National Fire Alarm and Signaling Code. Failure to test the fire alarm system as required could lead to system failure during an emergency, resulting in injury or death. The deficiency could affect all staff, residents, and visitors within the facility. The findings were: --- Document review on 07/01/2025 starting at 1:15 PM revealed the facility could not provide documentation demonstrating completion of the annual testing for manual fire alarm boxes, heat detectors, smoke damper operation, and smoke detector smoke entry, as well as the two (2) year smoke detector sensitivity testing. The inspection reports listed the number of devices located throughout the facility, but did not identify their locations, or that they had been tested. Additionally, the facility was only able to demonstrate that the quarterly testing of water flow and supervisory devices had been completed for three (3) of the last four (4) quarters. The facility was also unable to demonstrate that the fire alarm system had been activated on a monthly basis as required.Interview with the facility administrator and the facility maintenance manager at the time of observation acknowledged the deficiency, and indicated that they were aware of the requirements.Interview with the facility administrator at the time of exit confirmed the deficiency.REF: 2010 NFPA 72, Table 14.4.5

Based on observation and staff interview, the facility failed to maintain the installation of fire sprinkler systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 13, Standard for the Installation of Sprinkler Systems. Failure to maintain the installation of fire sprinkler systems could result in a failure of the system during an emergency, which could lead to injury or death. The deficiency could impact all staff, residents, and visitors within the facility. The findings were: --- Observation on 07/01/2025 at 11:22 AM in the northern closet of the Sanctuary Room revealed combustible items stored on the top shelf, which were located within two (2) to three (3) inches of the sprinkler head. A clear space of eighteen (18) inches must be maintained below sprinkler heads to prevent obstruction to the water spray pattern.Interview with the facility administrator and facility maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.Interview with the facility administrator at the time of exit confirmed the deficiency.REF: 2010 NFPA 13, Section 8.5.5

Based on document review and staff interview, the facility failed to test and maintain automatic sprinkler systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 13, Standard for the Installation of Sprinkler Systems. Failure to test and maintain automatic sprinkler systems as required could lead to system failure during an emergency, which could result in injury or death. The deficiency could impact all staff, residents, and visitors within the facility. The findings were: --- Document review on 07/01/2025 starting at 1:15 PM revealed the facility failed to conduct all required tests of the sprinkler dry system. The facility could not provide documentation demonstrating that the annual valve trip test had been conducted in the last (12) months, or that the full flow test had been conducted in the last (3) years.Interview with the facility administrator and facility maintenance manager at the time of observation acknowledged the deficiency, and indicated that they were aware of the requirement.Interview with the facility administrator at the time of exit confirmed the deficiency.REF: 2010 NFPA 13, Section 13.4

Based on document review and staff interview, the facility failed to perform fire drills in accordance with the 2012 NFPA 101, Life Safety Code. Failure to perform fire drills as required could lead to staff and residents being unfamiliar with the required procedures during a fire, which could result in injury or death. The deficiency could impact all staff and residents within the facility. The findings were: --- Document review on 07/01/2025 starting at 1:15 PM revealed that the facility had not performed fire drills during the first quarter of 2025, and had only performed drills during the day shift for the third quarter of 2024, and the 2nd quarter of 2025. Fire drills must be performed once per quarter per shift on an annual basis.Interview with the facility administrator and facility maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.Interview with the facility administrator at the time of exit confirmed the deficiency.REF: 2012 NFPA 101, Section 18.7.1.6

Based on document review and staff interview, the facility failed to perform annual inspection of fire-rated doors in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 80, Standard for Fire Doors and Other Protective Openings. Failure to inspect fire-rated doors as required could result in equipment failure during an emergency, resulting in injury or death. The deficiency could impact all staff and residents within the facility. The findings were: --- Document review on 07/01/2025 starting at 1:15 PM revealed that testing of the fire-rated doors had been performed by the facility maintenance manager. However, the facility failed to demonstrate that the facility maintenance manger possessed the appropriate training and certification to perform the testing in accordance with NFPA 80.Interview with the facility administrator and facility maintenance manager at the time of observation acknowledged the deficiency, and indicated that they were not aware of the training and qualification requirements.Interview with the facility administrator at the time of exit confirmed the deficiency.REF: 2012 NFPA 101, Sections 18.7.6 and 4.6.12, and NFPA 80, Section 5.2.1

Based on document review and staff interview, the facility failed to test and maintain main and feeder circuit breakers in accordance with the 2012 NFPA 99, Health Care Facilities Code. Failure to test and maintain main and feeder circuit breakers as required could result in faulty or inoperable equipment, resulting in injury or death. The deficiency could impact all staff, residents and visitors within the facility. The findings were: --- Document review on 07/01/2025 starting at 1:15 PM revealed that the facility did not have an established program for inspecting and exercising electrical components in accordance with the manufacturer's recommendations. Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established based on the manufacturer's recommendations.Interview with the facility administrator and facility maintenance manager at the time of observation acknowledged the deficiency, and indicated that they were not aware of the requirement.Interview with the facility administrator at the time of exit confirmed the deficiency.REF: 2012 NFPA 99, Section 10.4.4.1.2

Based on document review and staff interview, the facility failed to test and maintain Patient Care Related Electrical Equipment (PCREE) in accordance with the 2012 NFPA 99, Health Care Facilities Code. Failure to properly test and maintain PCREE could result in equipment failure, resulting in injury or death. The deficiency affected all PCREE throughout the facility, and could potentially affect residents and staff utilizing the equipment. The findings were: --- Document review on 07/01/2025 starting at 1:15 PM revealed that the facility failed to test all PCREE for electrical safety. No documentation was available to demonstrate that the facility was conducting the required testing for physical integrity, resistance, leakage current, and touch current. Testing shall include all equipment and appliances intended for diagnosis, therapeutics, or monitoring, which includes electric beds and patient lifts.Interview with the the facility administrator and facility maintenance manager at the time of observation acknowledged the deficiency, and indicated that they were unaware of the requirement.Interview with the facility administrator at the time of exit confirmed the deficiency.REF: 2012 NFPA 99, Section 10.3

Based on document review and staff interview, the facility failed to provide an all-hazards approach as a part of their facility-based and community-based risk assessment in accordance with §418.113(a). Failure to provide an all-hazards approach in development of the emergency preparedness plan could result in inadequate planning and response to an emergency. The deficiency affected the risk assessment portion of the emergency preparedness plan. The findings were: Document review of the emergency preparedness plan on 07/07/2022 starting at 10:15 AM revealed that the facility's risk assessment did not include communicable diseases as a part of their all-hazards approach. Interview with the facility administrator and facility maintenance manager at the time of the observation acknowledged the deficiency, and indicated they were unaware of the requirement Interview with the facility administrator at the time of exit acknowledged the deficiency. .

Based on document review and staff interview, the facility failed to provide subsistence needs for staff and patients as a part of their emergency preparedness plan in accordance with §418.113(b)(6)(iiii). Failure to develop and maintain adequate supply chains for food, water, fuel, and waste disposal could lead to harm of staff and residents during an emergency. The deficiency affected the emergency preparedness plan. The findings were: Document review of the emergency preparedness plan on 07/07/2022 starting at 10:15 AM revealed that the emergency preparedness plan did not include information to address subsistence needs for staff and residents outside of inventory already provided within the facility; a means to secure fuel for the emergency generator during an extended power outage; or sewage and waste disposal accommodations for staff and residents during an extended emergency event. Interview with the facility administrator and the facility maintenance manager at the time of the observation acknowledged the deficiency, and indicated they were unaware of the requirement. Interview with the facility administrator at the time of exit acknowledged the deficiency. .

Based on document review and staff interview, the facility failed to develop and maintain emergency preparedness contact information in accordance with §483.73(c). Failure to develop and maintain the emergency preparedness contact information could result in the supervising agency not being notified in an emergency. The deficiency affected the contact list in the emergency preparedness plan. Document review on 07/07/2022 starting at 10:15 AM revealed that the contact list in the emergency preparedness plan was missing contact information for the State Licensing and Certification Agency. Interview with the facility administrator and the facility maintenance manager at the time of observation acknowledged the deficiency, and indicated they were unaware of the requirement. Interview with the administrator at the time of exit acknowledged the deficiency. .

Based on document review and staff interview, the facility failed to test battery-powered emergency lighting in accordance with the 2012 NFPA 101, Life Safety Code. Failure to test emergency lighting as required could lead to injury or death during an emergency. The deficiency could affect all staff and residents within the facility. The findings were: Document review on 07/07/2022 starting at 10:15 AM could not produce documentation indicating that the facility had been performing the required 30 second monthly, and 90 minute annual, battery test for battery-powered emergency light fixtures. Interview with the facility administrator and facility maintenance manager at the time of the observation acknowledged the deficiency, and indicated they were aware of the requirement. Interview with the facility administrator at the time of exit acknowledged the deficiency. REF: 2012 NFPA 101, Section 7.9.3.1 .

Based on observation and staff interview, the facility failed to store alcohol-based hand-rub fluid in accordance with the 2012 NFPA 101, Life Safety Code. Failure to store flammable liquids as required increases the risk of fire, and could result in injury or death. The deficiency could affect all staff and residents within the facility. The findings were: Observation on 07/07/2022 at 9:20 AM in the conference room closet revealed a total of 8.5 gallons of 85% alcohol-based hand rub in storage. Further observation revealed that the storage closet was not fire-rated, or protected in accordance with hazardous location requirements. Interview with the facility maintenance manager at the time of the observation acknowledged the deficiency, and indicated he was not aware of the requirement. Interview with the facility administrator and facility maintenance manager at the time of exit acknowledged the deficiency. REF: 2012 NFPA 101, Section 18.3.2.6(7) .

Based on document review and staff interview, the facility failed to test the fire alarm system in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 72, National Fire Alarm and Signaling Code. Failure to test the fire alarm system as required could lead to system failure during an emergency, resulting in injury or death. The deficiency could affect all staff and residents within the facility. The findings were: Document review on 07/07/2022 starting at 10:15 AM revealed that the facility could not provide documentation demonstrating monthly activation of the fire alarm, annual in-place smoke entry testing for smoke detectors, annual tabulated pass/fail of all notification devices, annual smoke damper operation, and quarterly water flow and supervisory equipment testing. Interview with the facility administrator and the facility maintenance manager at the time of the observation acknowledged the deficiency, and indicated they were aware of the requirement. Interview with the facility administrator at the time of exit acknowledged the deficiency. REF: NFPA 72, Table 14.4.5 .

Based on document review and staff interview, the facility failed to test and maintain automatic sprinkler systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2012 NFPA 13, Standard for the installation of Sprinkler Systems. Failure to test and maintain automatic sprinkler systems as required could lead to system failure during an emergency, which could result in injury or death. The deficiency could impact all staff and residents within the facility. The findings were: Document review on 07/07/2022 starting at 10:15 AM revealed the facility could not provide documentation demonstrating that the annual auxiliary drain and valve trip test, as well as the quarterly priming water, low air alarm, and quick opening devices testing had been performed. Interview with the facility administrator and facility maintenance manager at the time of the observation acknowledged the deficiency, and indicated they were aware of the requirement. Interview with the facility administrator at the time of exit acknowledged the deficiency. REF: 2010 NFPA 13 Section 13.4 .

Based on document review and staff interview, the facility failed to test and maintain fire dampers in accordance with the 2012 NFPA 101, Life Safety Code, the 2012 NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, and the 2010 NFPA 80, Standard for Fire Doors and Other Opening Protectives. Failure to test and maintain fire dampers as required lead to system failure, and contribute to the spread of fire during an emergency. The deficiency could impact all staff and residents within the facility. The findings were: Document review on 07/07/202 starting at 10:15 AM revealed that the facility could not provide documentation to demonstrate that fire dampers throughout the facility have been tested and maintained every four years as required. Interview with the facility administrator and facility maintenance manager at the time of the observation acknowledged the deficiency, and indicated they were not aware of the requirement. Interview with the facility administrator at the time of exit acknowledged the deficiency. REF: 2012 NFPA 101, Section 18.5.2.1 and 9.2.1 2012 NFPA 90A, Section 5.4.8.1 2010 NFPA 80, Section 19.4.1.1 .

Based on document review and staff interview, the facility failed to perform fire drills in accordance with the 2012 NFPA 101, Life Safety Code. Failure to perform fire drills as required could lead to staff and residents being unfamiliar with the required procedures during a fire, which may result in injury or death. The deficiency could affect all staff and residents within the facility. The findings were: Document review on 07/07/2022 starting at 10:15 AM revealed that the facility had performed day shift drills during the months of 10/2021, 12/2021, 02/2022, and 05/2022. Fire drills must be performed once per quarter per shift on an annual basis. Interview with the facility administrator and facility maintenance manager at the time of the observation acknowledged the deficiency, and indicated they were aware of the requirement. Interview with the facility administrator at the time of exit acknowledged the deficiency. REF: NFPA 101, Section 18.7.1.6 .

Based on document review and staff interview, the facility failed to perform annual inspection of fire-rated doors in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 80, Standard for Fire Doors and Other Protective Openings. Failure to inspect fire-rated doors as required could result in equipment failure during an emergency, resulting in injury or death. The deficiency could impact all staff and residents within the facility. The findings were: Document review on 07/07/2022 starting at 10:15 AM revealed the facility had been performing the required inspection of fire-rated doors for only the cross-corridor doors at the smoke compartment wall. Inspections must include all fire-rated doors at hazardous locations throughout the facility. Interview with the facility administrator and facility maintenance manager at the time of the observation acknowledged the deficiency, and indicated they were not aware of the requirement. Interview with the facility administrator at the time of exit acknowledged the deficiency. REF: 2012 NFPA 101, Sections 18.7.6 and 4.6.12 2010 NFPA 80, Section 5.2.1 .

Based on document review and staff interview, the facility failed to test lead acid batteries for emergency power generation equipment in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 110, Standard for Emergency and Standby Power Systems. Failure to test batteries as required could lead to failure during an emergency, and could lead to injury or death in the event of a power outage. The deficiency could impact all staff and residents within the facility. The findings were: Document review on 07/07/2022 starting at 10:15 AM revealed that the facility was not performing the required monthly testing for the lead acid battery of the emergency generator. Interview with the facility administrator and facility maintenance manager at the time of the observation acknowledged the deficiency, and indicated they were not aware of the requirement. Interview with the facility administrator at the time of exit acknowledged the deficiency. REF: 2010 NFPA 110, Section 8.3.7.1

Based on observation, staff interview and facility policy review, the facility failed to ensure all resident drugs were stored in locked compartments within a secure storage area. Facility census was 6. The findings were: 1. Observation of the medication room showed resident medications were in a medication cart with unlocked drawers. Further observation of the medication room showed that resident #2 had 20 tablets of hydrocodone-acetaminophen 7.5-325 mg in the unlocked cart. 2. Observation in the nurse's station showed a locked "mini-fridge" with a clear plastic door. Visible through the door was a prescription of lorazepam in a 30 ml bottle for resident #5 and another prescription of lorazepam in a 30 ml bottle for resident #7. 3. Interview with RN #4 on 7/5/22 at 12:21 PM revealed that the cart locked and he/she had the key but failed to lock the cart. 4. Interview with the DON on 7/5/22 at 1:30 PM confirmed the "mini-fridge" should be located in a secure area. 5. Review of facility policy "Medication-Labeling, Dispensing, Disposing and Storing of Drugs and Biologicals'' dated 6/22, showed for an inpatient facility, the hospice "will ensure that all drugs and biologicals are stored in secure areas"...and the hospice "will ensure that all controlled drugs...are stored in locked compartments within such secure storage areas."