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Complaint Investigation

Summit Ridge Skilled Nursing & Rehabilitation

September 17, 2025 · Douglas, WY · 1108 Birch Street
Citations 2
CMS Rating 2/5
Beds 60
Provider ID 535040
Healthcare Facility
Summit Ridge Skilled Nursing & Rehabilitation
Douglas, WY  ·  View full profile →
Inspection Summary

Summit Ridge Skilled Nursing & Rehabilitation in Douglas, WY — inspection on September 17, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0600
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Actual Harm

will provide protections for the health, welfare and rights of each resident and prohibit abuse.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Summit Ridge Skilled Nursing & Rehabilitation

1108 Birch Street Douglas, WY 82633

SUMMARY STATEMENT OF DEFICIENCIES

Review of the significant change MDS assessment dated [DATE] showed resident #1 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included hypertension, diabetes mellitus, and arthritis.

Further review showed the resident required partial to moderate assistance with bathing and was wheelchair bound.

Review of the resident's care plan dated 8/26/25 showed that the resident had alterations in ADL function secondary to weakness and pain and required assistance completing ADL task's The following concerns were identified:a.

Interview with the resident on 9/16/25 at 11:33 AM revealed the resident, at times, had gone several days without a shower.

The resident revealed s/he didn't have a specific time preference as long as s/he was offered a shower every couple of days. b.

Interview with the resident's representative on 9/16/25 at 11:21 AM revealed the resident had gone several days without being offered a shower in the past and prior to admission the resident would shower daily.

Further the representative revealed at the time of admission, the resident had requested showers three times per week. c.

Review of the facility bathing schedule showed the resident was scheduled three times weekly on Monday, Wednesday, and Fridays for showering. d.

Review of the resident's bathing history from 7/1/25 through 9/17/25 showed the resident was not provided or offered a shower between 7/8/25 and 7/17/25 (10 days) and between 8/14/25 and 8/22/25 (9 days). e.

Interview with the DON on 9/17/25 at 10:59 AM revealed residents were offered showers on their scheduled days and according to their preference, unless the resident refused or was unavailable.

She revealed staff were expected to document the bathing and any refusals. f.

Interview with the DON on 9/17/25 at 1:28 PM confirmed there was no documentation the resident received or was offered a shower between the dates of 7/8/25 and 7/17/25 or 8/14/25 and 8/22/25. 2.

Review of the facility policy titled Resident Showers last revised 4/2025 showed .Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. 3.

Review of the facility policy titled Activities of Daily Living - ADL's last revised 4/2025 showed .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal hygiene.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Douglas, WY, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Summit Ridge Skilled Nursing & Rehabilitation or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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