Central Wyoming Hospice Program

“Based on document review and staff interview, the facility failed to provide an Emergency Preparedness Plan (EPP) with policies and procedures in accordance with §418.113(b)(6)(C)(iv). The EPP failed to outline the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. The findings were: Review of the EPP on 01/13/202 starting at 11:00 AM revealed that the facility’s EPP failed to develop and implement policies and procedures which outline the facility’s role in the provision of care and treatment under section 1135 waivers during a declared public health emergency in alternate care sites. Interview with the facility administrator and the facility maintenance manager at the time of the observation acknowledged the deficiency.Interview with the facility administrator and the facility maintenance manager at the time of exit confirmed the deficiency.”

“Based on observation and staff interview, the facility failed to maintain the means of egress in the Kloefkorn Building in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain the means of egress could lead to injury or death in the event of an emergency. The deficiency affected one (1) of multiple means of egress. The deficiency could affect all residents, staff, and visitors at the facility. The findings were: Observation on 01/13/2026 at 10:27 AM revealed a pair of 3/4 hour fire rated cross corridor doors with hold open devices in the exit access corridor in the Kloefkorn building. Both doors closed and latched when dropped from their magnetic hold open devices. Further observations revealed the exit hardware on the east door failed to release the door latch leaving the door inoperable after it closed. The inoperable door created an obstruction within the means of egress.Interview with the facility administrator and the facility maintenance manager at the time of the observation acknowledged the deficiency.Interview with the facility administrator and the facility maintenance manager at the time of exit confirmed the deficiency. REF: 2012 NFPA 101, Sections 19.2.1, 7.1.10.1, 7.2.1.5.1”

“Based on observation and staff interview in the Chapman Building, the facility failed to ensure doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position unless held open by a release device in accordance with the 2012 NFPA 101, Life Safety Code. Failure to ensure self-closing doors close and latch could allow for the spread of smoke and fire leading to injury or death in the event of a fire. The deficiency affected one (1) of multiple doors and could potentially affect all residents, staff, and visitors. The findings were: Observation on 01/13/2026 at 9:50 AM in the Chapman building revealed the Janitor’s Closet was protected with a fire rated self-closing door. Further observation revealed the self-closing door failed to close and latch when dropped from the open position.Interview with the facility administrator and the facility maintenance manager at the time of the observation acknowledged the deficiency.Interview with the facility administrator and the facility maintenance manager at the time of exit confirmed the deficiency.REF: 2012 NFPA 101, Sections 19.2.2.2.7, 19.3.2.1, 19.3.2.1.3 Observation on 01/13/2026 at 10:39 AM in the Kloefkorn building revealed the Pantry storage room was protected with a fire rated self-closing door. Further observation revealed the self-closing door failed to close and latch when dropped from the open position.Interview with the facility administrator and the facility maintenance manager at the time of the observation acknowledged the deficiency.Interview with the facility administrator and the facility maintenance manager at the time of exit confirmed the deficiency.REF: 2012 NFPA 101, Sections 19.2.2.2.7, 19.3.2.1, 19.3.2.1.3”

“Based on document review and staff interview, the facility failed to test battery-operated emergency lighting and exit signs at the Kloefkorn building in accordance with the 2012 NFPA 101, Life Safety Code. Failure to test battery-operated emergency lighting equipment as required could result in inadequate lighting or failure to identify exit access during an emergency, resulting in injury or death. The deficiency impacted all battery powered exit signage and emergency lighting throughout the facility. The findings were: Document review on 01/13/2026 starting at 11:00 AM revealed the facility failed to provide evidence of required 30 second functional testing of the battery-operated emergency lighting and exit signs at the Kloefkorn building for the months of July and August of 2025. The 2012 NFPA 101, section 7.9.3.1.1 requires monthly functional testing of battery powered emergency lighting and exit signs for not less than 30 seconds.Interview with the facility administrator and the facility maintenance manager at the time of the observation acknowledged the deficiency.Interview with the facility administrator and the facility maintenance manager at the time of exit confirmed the deficiency.REF: 2012 NFPA 101, Sections 19.2.9, 19.2.10, 7.9.3.1, 7.10.9.2 Document review on 01/13/2026 starting at 11:00 AM revealed the facility failed to provide evidence of required 30 second functional testing of the battery-operated emergency lighting and exit signs at the Chapman building for the months of July and August of 2025. The 2012 NFPA 101, section 7.9.3.1.1 requires monthly functional testing of battery powered emergency lighting and exit signs for not less than 30 seconds.Interview with the facility administrator and the facility maintenance manager at the time of the observation acknowledged the deficiency.Interview with the facility administrator and the facility maintenance manager at the time of exit confirmed the deficiency.REF: 2012 NFPA 101, Sections 19.2.9, 19.2.10, 7.9.3.1, 7.10.9.2”

“Based on observation, document review and staff interview, the facility failed to maintain and provide documentation of required maintenance for the water-based fire protection systems at the Kloefkorn Building in accordance with 2012 NFPA 101, Life Safety Code, and 2011 NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Failure to test and maintain water-based fire protection systems could result in injury or death in the event of a fire. The deficiency could affect the entire fire sprinkler system. The findings were: Document review on 01/13/2026 starting at 11:00 AM for the Kloefkorn building revealed the facility failed to provide evidence of internal inspection of piping as required by the 2011 NFPA 25, section 14.2. An internal inspection of the fire sprinkler system’s piping and branch line conditions shall be conducted every 5 years. Interview with the facility administrator and the facility maintenance manager at the time of the observation acknowledged the deficiency.Interview with the facility administrator and the facility maintenance manager at the time of exit confirmed the deficiency.REF: 2012 NFPA 101, Section 9.7.5, 2010 NFPA 25, Section 14.2 Document review on 01/13/2026 starting at 11:00 AM for the Chapman building revealed the facility failed to provide evidence of internal inspection of piping as required by the 2011 NFPA 25, section 14.2. An internal inspection of the fire sprinkler system’s piping and branch line conditions shall be conducted every 5 years. Interview with the facility administrator and the facility maintenance manager at the time of the observation acknowledged the deficiency.Interview with the facility administrator and the facility maintenance manager at the time of exit confirmed the deficiency.REF: 2012 NFPA 101, Section 9.7.5, 2010 NFPA 25, Section 14.2”

“Based on document review and staff interview, the facility failed to provide documentation of fire drills conducted quarterly on each shift under varied conditions at the Chapman building in accordance with 2012 NFPA 101, Life Safety Code. Failure to conduct fire drills quarterly for all shifts and under varied conditions could lead to confusion or delay response resulting in injury or death in the event of a fire emergency. The deficiency could affect all residents, staff, and visitors. The findings were: Document review on 01/13/2026 starting at 11:00 AM revealed the facility failed to conduct fire drills quarterly on each shift under varied conditions at the Chapman building. The facility failed to provide evidence of a second shift fire drill occurring during the fourth quarter of 2025. Interview with the facility administrator and the facility maintenance manager at the time of the observation acknowledged the deficiency.Interview with the facility administrator and the facility maintenance manager at the time of exit confirmed the deficiency.REF: 2012 NFPA 101, Section 19.7.1 Document review on 01/13/2026 starting at 11:00 AM revealed the facility failed to conduct fire drills quarterly on each shift under varied conditions at the Kloefkorn building. The facility failed to provide evidence of a second shift fire drill occurring during the fourth quarter of 2025. Interview with the facility administrator and the facility maintenance manager at the time of the observation acknowledged the deficiency.Interview with the facility administrator and the facility maintenance manager at the time of exit confirmed the deficiency.REF: 2012 NFPA 101, Section 19.7.1”

“Based on document review and staff interview, the facility failed to implement the emergency power system inspection, testing and maintenance requirements found in the 2012 NFPA 99, Health Care Facilities Code, and 2010 NFPA 110, Standard for Emergency and Standby Power Systems, and the 2012 NFPA 110, Life Safety Code. Failure to provide the required inspection, testing, and maintenance of emergency power systems could lead to injury or death for all residents and staff in the event of an electrical system failure or emergency. The deficiency affected all of the emergency power systems at the Chapman building. The deficiency could potentially affect all residents, staff, and visitors. The findings were: Document review on 01/13/2026 starting at 11:00 AM revealed the facility’s Emergency Power Supply Systems for the Chapman building were not tested and maintained in accordance with the 2010 NFPA 110 Standard for Emergency and Standby Power Systems, and the 2012 NFPA 99, Healthcare Facilities Code. Document review revealed the facility failed to provide evidence of the following: Emergency Power Supply System (EPSS) main and feeder circuit breakers shall be inspected annually and a program established for exercising components per manufacturer’s recommendations.Interview with the facility administrator and the facility maintenance manager at the time of the observation acknowledged the deficiency.Interview with the facility administrator and the facility maintenance manager at the time of exit confirmed the deficiency.REF: 2012 NFPA 99, Section 6.4.4.1.2, and 2010 NFPA 110, Section 8.4.9 Document review on 01/13/2026 starting at 11:00 AM revealed the facility’s Emergency Power Supply Systems for the Kloefkorn building were not tested and maintained in accordance with the 2010 NFPA 110 Standard for Emergency and Standby Power Systems, and the 2012 NFPA 99, Healthcare Facilities Code. Document review revealed the facility failed to provide evidence of the following: Emergency Power Supply System (EPSS) main and feeder circuit breakers shall be inspected annually and a program established for exercising components per manufacturer’s recommendations.Interview with the facility administrator and the facility maintenance manager at the time of the observation acknowledged the deficiency.Interview with the facility administrator and the facility maintenance manager at the time of exit confirmed the deficiency.REF: 2012 NFPA 99, Section 6.4.4.1.2, and 2010 NFPA 110, Section 8.4.9”

“Based on observation and staff interview, the facility failed to properly handle and store gas cylinders in the Kloefkorn building in accordance with 2012 NFPA 99, Healthcare Facilities Code. Failure to properly handle and store compressed gas cylinders could result in injury or death in the event of accident or fire. The deficiency could affect all residents, staff, and visitors within the affected area. The findings were: Observations on 01/13/2026 at 10:20 AM in the Kloefkorn building revealed the facility failed to provide proper storage for nonflammable gas cylinders. The facility allowed for storage of compressed oxygen E-cylinders with a total volume greater than 300 cu. ft. compressed to be stored in an interior storage room within 5 ft of combustible supplies. Further observations of the oxygen storage room in the Kloefkorn building revealed the facility failed to provide the proper precautionary signage in accordance with the 2012 NFPA 99, section 11.3.4.Interview with the facility maintenance manager and the facility administrator at the time of the observation acknowledged the deficiency.Interview with the facility maintenance manager and the facility administrator at the time of exit confirmed the deficiency.REF: 2012 NFPA 99 Section 11.3, 11.3.2, 11.3.3, 11.3.4 Observations on 01/13/2026 at 10:08 AM in the Chapman building revealed the facility failed to provide proper storage for nonflammable gas cylinders. The facility allowed for storage of compressed oxygen E-cylinders with a total volume greater than 300 cu. ft. compressed to be stored in an interior storage room within 5 ft of combustible supplies. Further observations of the oxygen storage room in the Chapman building revealed the facility failed to provide the proper precautionary signage in accordance with the 2012 NFPA 99, section 11.3.4.Interview with the facility maintenance manager and the facility administrator at the time of the observation acknowledged the deficiency.Interview with the facility maintenance manager and the facility administrator at the time of exit confirmed the deficiency.REF: 2012 NFPA 99 Section 11.3, 11.3.2, 11.3.3, 11.3.4”