South Lincoln Nursing Center
711 Onyx St, Kemmerer, WY 83101 · Government - Hospital district · 24 certified beds · (307) 877-5717 Medicaid only — no Medicare
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (5/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0568)
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 20.3% | 16.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 6.1% | 5.9% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 4.5% | 1.5% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 6.1% | 3.1% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 3.1% | 6.5% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.0% | 4.7% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 28.5% | 15.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 43.9% | 15.4% | 18.9% | worse |
| Long-stay residents with pressure ulcers | 0.0% | 4.6% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 34.8% | 22.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.3% | 21.8% | 17.1% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Staffing
How full it usually is: this home is certified for 24 beds and averages 16.6 residents a day — about 69% occupied, or roughly 7 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.80 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.53 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.65 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.79 hrs/resident/day on weekends vs 5.22 on weekdays — 27% thinner on weekends — a notable drop. RN hours go from 1.76 to 0.96 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · D2026-01-06 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of medical records, staff interview, policy and procedure review, and review of the State Survey Agency incident database, the facility failed to ensure injuries of unknown source were reported to the State Agency within the required timeframe for 2 of 2 residents (#1, #2) reviewed for unexplained injuries. The census was 16. The findings were: 1. Review of the facility's policy Abuse Prohibition, last reviewed December 2019, showed Reporting/Response 1. General Guidance: Alleged violations, including injuries of unknown source, will be reported immediately to the Administrator or designee and the investigative Task Force which consist of the Administrator, Risk Manager, Compliance Officer, and the immediate supervisor of the employee being investigated. Corrective action will be taken depending on the results of the investigation. 2. Time frames: Alleged violations will be reported to the Office of Healthcare Licensing and Surveys and the Department of Family Services within 24 (twenty-four) hours of the allegation. All allegations of abuse will be reported and the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-06 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, staff and resident interview, and policy and procedure review, the facility failed to initiate an investigation following an injury of unknown source for 2 of 2 residents (#1, #2) reviewed for unexplained injuries. The census was 16. The findings were: 1. Review of the 12/8/25 quarterly MDS assessment showed resident #1 had a BIMS score of 12 out of 15 (mild cognitive impairment); weighed 232 pounds; had not had any falls since the last assessment; required substantial/maximal assistance from staff for the mobility activities of daily living of rolling left and right, sitting to lying, lying to sitting on the side of the bed, sitting to standing, and transfers from a chair/bed-to a chair. The resident was totally dependent on staff for toilet transfers. The following concerns were identified: a. Review of RN #1's progress notes on 12/4/25 showed the following: i. At 0407 (4:07 AM) this RN was in another resident's room when the CNA on shift came to this RN and stated I think you should come take a look at [resident room number], [s/he] is complaining…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-07-10 · tag F0837 — widespreadEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
What the surveyor found here — the official record, unedited, may be distressing
Based on staff interview, review of the facility change in personnel form, and review of Wyoming's active nursing home administrator's licenses, the Governing Body failed to employ a qualified nursing home administrator. The census was 18. The findings were:1. Review of the state survey agency Healthcare Facility Change in Personnel/E-mail Address Form showed the previous administrator was being changed to the Director of Quality and Compliance and a new administrator was named. The change was indicated as effective 6/16/25. 2. Review of the Wyoming State Board of Nursing Home Administrators Active Roster last updated on 7/14/25 showed the facility administrator did not hold an active license or an active provisional license.3. Interview with the facility administrator on 7/7/25 at 3:52 PM revealed the administrator was the CEO of the facility and confirmed he did not hold an active nursing home administrator's license.
- Potential for harm · E2025-07-10 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, medical record review, and policy and procedure review, the facility failed to ensure individual activities of preference were provided to 4 of 4 sample residents (#1, #5, #7, #18) reviewed for activities. The findings were: 1. Interview with 8 residents during resident council on 7/8/25 at 2:08 PM revealed the facility had not had any activities for at least 2 weeks and they felt there should be at least a daily activities.2. Review of the quarterly MDS assessment dated [DATE] showed resident #5 had a BIMS score of 9 out 15, which indicate moderate cognitive impairment, and diagnoses which included anxiety disorder, non-Alzheimer's dementia, and depression. Review of the annual MDS assessment dated [DATE] showed the resident indicated it was very important to listen to music, keep up with the news, do his/her favorite activity, and go outside to get fresh air when weather was good. Further review showed it was somewhat important to have books, newspapers, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-07-10 · tag F0680 — patternEnsure the activities program is directed by a qualified professional.
What the surveyor found here — the official record, unedited, may be distressing
Based on resident and staff interview, the facility failed to ensure the activities program was directed by a qualified professional. The census was 18. The findings were:1. Interview with 8 residents during resident council on 7/8/25 at 2:08 PM revealed activities had not been performed for at least 2 weeks and the activity director was being pulled to cover as a CNA. Further interview revealed the residents felt there should be daily activities.2. Interview with the activities director on 7/9/25 at 2:55 PM confirmed she was a CNA and did not have a background in recreation or activities. Further interview revealed she was taking an activities class at that time. 3. Interview with the activities director on 7/10/25 at 8:54 AM revealed she was not able to perform activities daily and she did work the floor as a CNA.
- Potential for harm · Ecited before2025-07-10 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and policy and procedure review, the facility failed to ensure proper infection control practices for 1 of 2 sample residents (#15) reviewed for urinary catheters or urinary tract infections and during 1 of 1 meal observation. The census was 18. The findings were:Regarding perineal care:1. Observation on 7/9/25 at 11:09 AM showed CNA #3 and CNA #4 entered the room of resident #15 and provided perineal care to the resident. During the observation, CNA #4 assisted the resident to roll towards her. While wearing gloves, CNA #3 removed the resident's brief. At that time, the resident was to noted to have been incontinent of feces and urine and had open areas on his/her buttocks. CNA #3 performed perineal care to remove the urine and feces. Without removing the contaminated gloves, the CNA applied a barrier cream to the resident's buttocks and open areas, assisted the resident with positioning by touching the resident's side and arms, and adjusted the residents clothing and bed linens. 2. Interview with the infection preventionist on 7/10/25 at 9:06…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-10 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy procedure review, the facility failed to ensure residents' right to elect a cardiopulmonary resuscitation (CPR) status for 2 of 12 sample residents reviewed (#16, #18) for advance directives. The findings were: 1. Review of the medical record for resident #16 showed there was no evidence the resident had made an election for CPR status. Review of the electronic health record showed the resident was indicated as do not resuscitate (DNR). 2. Interview with the quality assurance manager on [DATE] at 11:49 AM confirmed there was no evidence resident #16 had elected a DNR status.3. Review of the medical record for resident #18 showed no evidence the resident had made an election for CPR status. Further review showed a WyoPOLST dated [DATE] which indicated comfort focused therapy; however, the CPR and DNR boxes were left blank. Review of the electronic health record showed the resident was indicated as DNR.4. Interview with the DON [DATE] at 11:40 AM revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-10 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview, facility incident review, and policy and procedure review, the facility failed to protect the resident's right to be free from verbal abuse by a staff member for 1 of 2 sample residents (#2) reviewed with allegations of abuse. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #2 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included multiple sclerosis, depression, and manic depression. Further review showed the resident had upper and lower impairment bilaterally and required supervision and touching/steadying with eating. The following concerns were identified:a. Review of an incident report dated 4/18/24 showed the resident reported, on 4/7/24, CNA #1 was assisting the resident with eating when CNA #2 stated What, are you going to feed [him/her] like the fucking baby [s/he] is? Further review showed CNA #2 was placed on suspension and an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-10 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure as needed (PRN) psychotropic medications were limited to 14 days or there was a documented rationale for 1 of 5 sample residents (#18) reviewed for unnecessary medications. The findings were:1. Review of the admission MDS assessment dated [DATE] showed resident #18 had short-term and long-term memory problems and diagnoses which included Alzheimer's disease and non-Alzheimer's dementia. Further review showed the resident was taking antipsychotic, antianxiety, and antidepressant medications. The following concerns were identified:a. Review of the resident's physician orders showed the resident received lorazepam (antianxiety) 2 mg (milligrams)/1 ml (milliliter) solution 0.25-1 ml by mouth for anxiety every 4 hours as needed and haloperidol (anti-psychotic) 2 mg/1 ml solution 1 ml PRN by mouth every 4 hours for anxiety which were ordered on 5/22/25. Further review showed neither medication had a stop…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-03-28 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — the official record, unedited, may be distressing
Based on staff interview and personnel file review, the facility failed to ensure qualifications for the dietary manager were met. The census was 17. The findings were: 1. Interview with the dietary manager on 3/27/24 at 10:15 AM revealed she had not received any training before being hired as the dietary manager. 2. Review of the dietary manager's personnel record showed she received certification on 6/19/23 as a ServSafe Food Protection Manager; however, this certification had not been approved by CMS. 3. Interview with the human resource business partner on 3/28/24 at 12:29 PM revealed the dietary manager was hired as a food service professional on 9/7/22 and was promoted to supervisor on 1/16/23. 4. On 3/28/24 at 12:28 PM the director of quality and compliance officer acknowledged the ServSafe certification did not meet CMS guidelines.
Show the remaining 14 citations
- Potential for harm · F2024-03-28 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the resident council minutes, resident representative and staff interview, and review of the menu, the facility failed to follow the menu as written. The census was 17. The findings were: 1. Telephone interview with resident #8's representative on 3/26/24 at 3:34 PM revealed the menus were monotonous and everything seemed to either come out of a box or a can. The representative stated that she had attended a resident council meeting and the residents were unhappy about the food. 2. Review of the January, February, and March 2024 resident council minutes showed the following concerns: a. The January minutes showed Kitchen hired new staff-hopefully meals will be better. b. The February minutes showed Meals-Not so good-can't cut meat-too dry. c. The March minutes showed Meals: Still not the best-no flavor .Taco's good but not warm enough and no salsa. 3. Interview with the dietary manager on 3/27/24 at 1:30 PM revealed the dietitian had prepared a five-week menu; however, the facility started the menu over at the beginning of each month so the day of the week would…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-03-28 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, review of the dishwasher and refrigerator/freezer temperature log sheets, manufacturer's instructions, the dietitian site visit reports, hot and cold food temperature logs, and the 2022 FDA Food Code, the facility failed to ensure a sanitary environment in 1 of 1 kitchen. The census was 17. The findings were: Related to temperature monitoring of food storage units: 1. Review of the February and March 2024 temperature log sheets for food storage for the reach-in refrigerator, reach-in freezer, walk-in refrigerator and walk-in freezer showed the temperature of each unit was to be documented twice a day. The following concerns were identified: a. The temperature ranges of each storage unit was not defined on the log sheets. b. No temperatures were recorded on 2/6, 2/11, 2/12, 2/18, 2/23, 2/24, 2/25, 2/26, 3/2, 3/8, and 3/9. c. No evening temperatures were recorded on 2/5, 2/10, 2/16, 2/19, 2/22, 2/27, 3/3, 3/12, 3/19, and 3/20. d. No morning temperatures were recorded on 2/29,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-28 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure an advanced directive was formulated for 2 of 16 residents (#11, #14) reviewed. The findings were: 1. Review of the electronic medical record (EMR) showed resident #11 was listed as do not resuscitate (DNR). Further review of the medical record showed a WyoPOLST (Providers Orders for Life Sustaining Treatment), dated 1/18/21, which showed DNR with comfort-focused therapy was chosen. However, the form had not been signed by the resident or the resident's representative. 2. Review of the EMR showed resident #14 was listed as DNR. Further review of the medical record showed a WyoPOLST, dated 1/7/24, which showed DNR with selective treatment had been chosen. However, the form had not been signed by the resident's primary health care provider. 3. Interview with the director of quality and compliance officer on 3/26/24 at 4:20 PM confirmed the WyoPOLST form was incomplete. 4. Review of the 10/26/23 policy and procedure titled Clinical Protocol/Procedure Advance Directives showed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-28 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, staff interview, and complaint log review, the facility failed to ensure procedures were in place for the protection of resident property from loss or theft for 1 of 16 residents reviewed (#4). The findings were: 1. Interview with resident #4 on 3/26/24 at 8:28 AM revealed s/he was missing 6 undergarments and their little mesh bag the undergarments go into to be washed. 2. Review of the 2/27/24 at 4 PM quarterly care conference showed the facility had talked to the daughter related to (r/t) religious undergarments and found 2 in his/her dresser. The facility had looked in laundry without success; it was unknown if the resident was soiling and throwing them away. 3. Observation of laundry services on 3/28/24 at 9:31 AM showed only a pair of socks that were in the unknown resident box. The laundry service employee stated there was 1 mesh bag in the dryer at that time. 4. Interview with the DON on 3/28/24 at 9:33 AM revealed the facility did not track the missing items and show the outcome. She stated prior to this recent loss of belongings,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-28 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and staff interview, the facility failed to ensure residents with limited range of motion received the appropriate restorative services to increase range of motion and/or prevent further decline for 1 of 2 residents (#9) reviewed for restorative services. The findings were: 1. Review of the 2/15/24 quarterly MDS assessment showed resident #9 had a primary diagnosis of stroke. Review of the resident's care plan, last revised 2/23/24 showed AROM (active range of motion): [resident] is at risk for not being able to feed himself related to [his/her] history of cerebral infarction as evidenced by decreased ROM (range of motion) and fine motor skills in [his/her] upper extremities. The approaches included the restorative nurse aide (RNA) to assist the resident with 3 sets of 10 repetitions of upper and lower extremity AROM activities for 6 out of 7 days per week. The following concerns were identified: a. Review of the January 2024 restorative aide time tracking sheet showed the resident received AROM services on 1/25, and refused services on 1/15, 1/16,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-28 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure residents were monitored for side effects of psychotropic medications for 2 of 5 residents (#5, #9) reviewed for unnecessary medications. The findings were: 1. Review of the 3/27/24 quarterly MDS assessment showed resident #5 was admitted to the facility on [DATE] and had diagnoses which included anxiety disorder, depression, and intermittent explosive disorder. Review of the most recent physician orders showed the resident was prescribed fluoxetine HCl (an antidepressant) 20 milligrams (mg) daily on 12/30/19 and Abilify (an antipsychotic) 2.5 mg every other day on 11/5/21. The following concerns were identified: a. Review of the 1/25/24 Physician Rationale for Clinical Contraindication of Gradual Dose Reduction worksheet showed the side effects for fluoxetine HCl were identified as insomnia, fatigue, increased appetite, loss of sexual desire, and nausea. The side effects for Abilify were identified as blurred vision, dry mouth,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-28 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and profession standards review, the facility failed to ensure infection prevention techniques were followed for 3 random staff observations. The census was 17. The findings were: 1. Observation on 3/25/24 at 4:10 PM showed CNA #1 was carrying an unbagged, wadded-up incontinence pad down the hall from a resident's room with his/her bare hands. S/he then put the incontinence pad in the dirty utility room, and directly came out and walked back down the hall. S/he then took a hoyer lift to another resident's room without performing hand hygiene. 2. Observation on 3/25/24 at 4:30 PM showed RN #1 was working with medications and had gloves on. The RN put hand sanitizer on her gloves and scrubbed her hands together. Interview at that time with the nurse revealed it was ok to do that. She then stated she did not need to change her gloves, and that they were then clean. 3. Observation on 3/25/24 at 5:49 PM showed CNA #1 was served dinner to the residents. The CNA doffed her right hand glove and grabbed a food item out of a cabinet and handed it to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-26 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, and policy and procedure review, the facility failed to ensure necessary equipment was provided for 1 of 3 sample residents (#11) who were reviewed for positioning. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #11 had a BIMS score of 9 out of 15, which indicated moderate cognitive impairment, and diagnoses which included diabetes mellitus, non-Alzheimer's dementia, pain in left ankle and joints of left foot, pain in right ankle and joints of right foot, and age-related osteoporosis without current pathological fracture. The resident required total physical assistance of 2 or more people for transfers, extensive physical assistance of 1 person for locomotion on and off the unit, and had functional limitations in range of motion in his/her bilateral upper and bilateral lower extremities. Further review showed the resident was at risk for pressure ulcers. Review of the decreased mobility d/t [due to] hip…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-26 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, medical record review, and policy and procedure review, the facility failed to ensure as needed (PRN) orders for psychotropic medications were limited to 14 days for 1 of 5 sample residents (#17) and failed to ensure appropriate behavior monitoring and non-pharmacological interventions were in place for 2 of 5 sample residents (#3, #17) reviewed for unnecessary medications. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #3 had a BIMS score of 15 out 15, which indicated the resident was cognitively intact, and diagnoses which included multiple sclerosis, bipolar disorder, opioid dependency, and chronic pain syndrome. Further review showed the resident received antipsychotic and antidepressant medications on 7 out 7 days during the look back period. Review of the physician's orders dated January 2023 showed the resident received quetiapine fumarate (antipsychotic) 200 milligrams (mg) one tablet by mouth at bedtime, duloxetine HCL DR (antidepressant)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-07-10 · tag F0576 — widespreadEnsure residents have reasonable access to and privacy in their use of communication methods.
What the surveyor found here — the official record, unedited, may be distressing
Based on resident and staff interview, the facility failed to ensure mail was delivered to residents, including on Saturday. The census was 18. The findings were: 1. Interview with 8 residents during resident council on 7/8/25 at 2:08 PM revealed purchasing and receiving received all mail and was closed on the weekends. The residents revealed the closure of purchasing and receiving resulted in mail delivery not being performed on Saturdays. 2. Interview with quality assurance manager on 7/10/25 at 9:59 AM confirmed mail was not delivered on Saturdays because the facility did not have anyone available to receive it from the post office. Further interview revealed the post office added all mail received on the weekends to a box of mail which was delivered the following Monday.
- No harm found · C2025-07-10 · tag F0729 — widespreadVerify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on employee file review, staff interview, abuse registry review, and policy and procedure review, the facility failed to ensure abuse registry verification for 1 of 3 sample CNAs #3 prior to resident contact. The census was 18. The findings were:1. Review of the employee file for CNA #3 showed the CNA had an active license and had a start date of 2/10/25. Further review showed no evidence the CNA abuse registry was checked prior to resident contact. Review of the Wyoming CNA registry at that time showed no evidence the CNA had been added to the registry for verification.2. Interview with the human resources business partner on 7/10/25 at 11:04 AM confirmed there was no evidence of abuse registry verification for the CNA.3. Review of the facility policy titled Abuse Prohibition last reviewed December 2019 showed .Screening 1. Initial: The Human Resources Department will screen potential employees for a history of abuse, neglect, or mistreating patients/residents by : attempting to obtain information from previous employers and/or current employers; checking with the appropriate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2023-01-26 · tag F0727 — failed to provide required RN coverage — widespreadHave 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and review of job duties, the facility failed to ensure a full time DON. The census was 19. The findings were: 1. Review of a Job Duties Director of Nursing and Job Duties of Nursing Home Administrator provided by the DON 1/26/23 at 8:47 AM showed the DON position averaged about 32 hours per week broken up by 10-15 hours for training and development of clinical staff, 5-10 hours for coordination of nursing/CNA schedules, 5-10 hours for MDS coordination/completion, 24 hours monthly (1-2 times per month as needed) for charge nurse duties, 5 hours for care plan development, and 1-5 hours for communication with families and residents. The total range of DON duties was 26-45 hours plus the time as the charge nurse. The administrator position averaged about 32 hours per week and required 1-5 hours for development and review of policies and procedures, 1-5 hours for the quality assurance programs, 1-5 hours for coordination of care with other departments, 1-5 hours for preparation and monitoring of the annual budget, 1-3 hours for coordination of care with outside…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2023-01-26 · tag F0568 — patternProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — the official record, unedited, may be distressing
Based on resident and staff interview, and policy and procedure review, the facility failed to ensure resident fund account statements were provided at least quarterly. The census was 19. The findings were: 1. Interview with resident #3 on 1/24/23 at 2:49 PM revealed the resident had an account at the facility and had asked for statements; however, the facility had not provided any statements. 2. Interview with the DON on 1/26/23 at 9:12 AM revealed the facility performed a monthly tracking of funds and sent it out to family members; however, the copies did not indicate if or when it was sent to the resident or representative. Further interview revealed the facility was working to improve on the trust account process and she was not aware of any residents asking for statements. 3. Review of a policy titled Resident Funds last revised on 6/1/22 showed .1. Each month, a statement of current resident fund balances and transactions from the last month will be made available to the resident and/or guardians .
- No harm found · B2023-01-26 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to develop and implement a comprehensive person-centered care plan for 2 of 10 sample residents (#8, #14) reviewed for care plans. The findings were: 1. Observation on 1/24/23 at 11:23 AM showed resident #8 was in his/her room. There was a sign located above his/her bed reminding the resident to wear oxygen. Review of physician orders dated October 2019 showed oxygen was ordered for 2 liters of flow at night. Review of the quarterly MDS assessment dated [DATE] showed the resident used oxygen. Review of the resident's care plan provided by the quality assurance manager on 1/25/23 showed a care plan for oxygen use was not developed. 2. Observation on 1/24/23 at 2:44 PM showed resident #14 had both legs wrapped with ACE wraps (wide elastic wrap). Interview with the resident at that time revealed that s/he had congestive heart failure and always had to use their wheelchair and have both legs wrapped every day. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record. 2 Medicare payment denials on record.
- Medicare payment denial — starting 2026-03-28 for 5 days
- Medicare payment denial — starting 2025-10-10 for 59 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
What families pay in WY
CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Wyoming Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 53A051. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-10, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.