Heritage Home
Heritage Home in Pinedale, WY — inspection on August 19, 2025.
Found 1 citation. 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.
Inspection Findings
Review of the admission Minimum Data Set assessment dated [DATE] showed resident #1 had a brief interview for mental status score of 3 out of 15, which indicated severe cognitive impairment, and had diagnoses which include heart failure, atrial fibrillation, renal insufficiency and diabetes mellitus.
Further review showed the resident was insulin dependent for diabetes mellitus.
The following concerns were identified: a.
Review of the facility incident report dated 7/18/25 showed a potential medication error for resident #1 involving sliding scale insulin administration. b.
Review of physician orders dated 7/10/2025 for sliding scale insulin showed the resident was to receive 8 units of insulin for blood sugars ranging from 351-400 mg/dl (milligrams per deciliter). c.
Review of the resident's medication administration record dated 7/18/25 showed the residents blood sugar was 377 mg/dl prior to insulin administration.d.
Review of the Mediation Error Report dated 7/18/25 showed registered nurse (RN) #1 administered 80 units of insulin instead of 8 units on 7/18/25.
Further review showed the resident was transferred to an acute care hospital setting following the insulin administration utilizing the wrong type of syringe. e.
Review of nursing report titled; Supplemental Statement of Events dated 7/19/25 showed RN #1 documented 8 units of insulin was administered to the resident at approximately 4:30 PM on 7/18/25.
Further review showed the resident was not acting like him/herself and exhibited diaphoresis, cool skin, rapid breathing, and changes in level of consciousness. f.
Review of the hospital physician note dated 7/19/25 showed the resident was admitted to the Intensive Care Unit for management for hypoglycemia and hypotension following accidental insulin overdose. g.
Interview with RN #1 on 8/19/25 at 10:08 AM confirmed the resident was administered 80 units of insulin instead of 8 units on 7/18/25 at approximately 4:30 PM.
She revealed during administration of the insulin, she utilized a tuberculin syringe instead of an insulin syringe because she couldn't find any insulin syringes.h.
Interview with the director of nursing on 8/19/25 at 9 AM confirmed the wrong insulin dose was administered due to the nurse utilizing the wrong syringe for administration.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.