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🔎 Thermopolis Rehabilitation And Wellness

Inspection Results


Inspection Overview

Thermopolis Rehabilitation And Wellness has been cited for a total of 35 deficiencies since we began saving each survey.

In Wyoming, the average facility has **29.63 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey Date: 2024-06-27
Correction Date: 2024-07-31
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: G

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2024-03-06
Correction Date: 2024-04-01
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: K

Respond appropriately to all alleged violations.

Survey Date: 2024-03-06
Correction Date: 2024-04-01
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: G

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2023-08-22
Correction Date: 2023-09-13
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2023-04-20
Correction Date: 2023-05-31
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Survey Date: 2023-04-20
Correction Date: 2023-05-31
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2023-04-20
Correction Date: 2023-05-31
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2023-04-20
Correction Date: 2023-05-31
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: G

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2023-03-10
Correction Date: 2023-03-30
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2023-03-10
Correction Date: 2023-03-30
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: J

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2023-01-13
Correction Date: 2023-02-09
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Survey Date: 2023-01-13
Correction Date: 2023-02-09
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-01-13
Correction Date: 2023-01-13
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.

Survey Date: 2023-01-13
Correction Date: 2023-02-09
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.

Survey Date: 2023-01-13
Correction Date: 2023-02-09
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: E

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Survey Date: 2023-01-13
Correction Date: 2023-02-09
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2022-03-31
Correction Date: 2022-05-14
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2022-03-31
Correction Date: 2022-05-14
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: B

Post nurse staffing information every day.

Survey Date: 2022-03-31
Correction Date: 2022-05-14
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2022-03-31
Correction Date: 2022-05-14
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2022-03-31
Correction Date: 2022-05-14
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Implement a program that monitors antibiotic use.

Survey Date: 2022-03-31
Correction Date: 2022-05-14
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Plan the resident's discharge to meet the resident's goals and needs.

Survey Date: 2021-04-28
Correction Date: 2021-06-12
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Survey Date: 2021-04-28
Correction Date: 2021-06-12
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Survey Date: 2021-04-28
Correction Date: 2021-06-12
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2021-04-28
Correction Date: 2021-06-12
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure residents have reasonable access to and privacy in their use of communication methods.

Survey Date: 2019-05-22
Correction Date: 2019-07-06
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2019-05-22
Correction Date: 2019-07-06
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Assess the resident when there is a significant change in condition

Survey Date: 2019-05-22
Correction Date: 2019-07-06
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Survey Date: 2019-05-22
Correction Date: 2019-07-06
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2019-05-22
Correction Date: 2019-07-06
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide activities to meet all resident's needs.

Survey Date: 2019-05-22
Correction Date: 2019-07-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Survey Date: 2019-05-22
Correction Date: 2019-07-06
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2019-05-22
Correction Date: 2019-07-06
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2019-05-22
Correction Date: 2019-07-06
Category: Infection Control Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**