Worland Health and Rehabilitation: Medication Mix-Up - WY
Inspectors found the cup on April 30, 2026, at 12:14 in the afternoon. The resident told them what had happened: a traveling nurse had come in some months earlier and offered a sodium chloride salt pill. The resident, who had been prescribed sodium bicarbonate for acute kidney failure, noticed the pill didn't look right. When the resident raised the concern, the nurse said it didn't make a difference, that the two medications did the same thing. The resident refused anyway. The nurse left the pill and walked out.
Sodium bicarbonate and sodium chloride are not the same medication. Sodium bicarbonate is used to treat the acid buildup that accompanies kidney failure. Sodium chloride is salt. For a patient with high blood pressure and chronic kidney disease, the distinction is not a minor one.
The physician's orders confirmed the resident had a standing order for sodium bicarbonate, 325 milligrams, two tablets by mouth twice daily. There was no order for sodium chloride anywhere in the chart.
When the director of nursing was interviewed at 12:35 that afternoon, she said the unlabeled pill was an over-the-counter medication. She could not identify what it was. She did not know when the nurse had given it to the resident. She could not confirm whether it had been documented on the medication administration record. What she said she expected was that nurses watch residents take their medications — which, in this case, had not happened, and had instead produced the opposite outcome: an unidentified pill sitting loose in an unlabeled cup in a resident's room for an unknown number of months.
There was no self-administration assessment in the resident's medical record, which would have been required before a resident could be permitted to keep and manage their own medications. Without that assessment, the facility had no documented basis for leaving any medication in that resident's possession.
The regional clinical nursing director, interviewed at 1:05 that afternoon, confirmed something that made the individual failures harder to dismiss as isolated: the facility had no policy on medication administration.
Not an outdated policy. Not a policy under revision. No policy.
A 64-bed facility caring for residents with complex diagnoses — kidney disease, hypertension, cardiac conditions — had no written guidance governing how nurses were supposed to handle, verify, administer, or document medications.
That absence helps explain how a traveling nurse could substitute one drug for another, tell a patient the difference didn't matter, leave an unlabeled pill in an unlabeled cup, and apparently face no immediate consequence. It helps explain how the director of nursing, months later, could not say whether any of it had been recorded. There was no framework requiring her to know.
The resident, for their part, had done everything right. They recognized the pill wasn't what they'd been prescribed. They refused it. They told the inspector exactly what had happened.
The pill was still there when inspectors arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Worland Health and Rehabilitation from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 6, 2026 · Our methodology
Worland Health and Rehabilitation in Worland, WY was cited for violations during a health inspection on April 30, 2026.
Inspectors found the cup on April 30, 2026, at 12:14 in the afternoon.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.