Green House Living For Sheridan
Inspection history, citations, penalties and survey trends for this long-term care facility in Sheridan, Wyoming.
- Location
- 2311 Shirley Cove, Sheridan, Wyoming 82801
- CMS Provider Number
- 535054
- Inspections on file
- 21
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Green House Living For Sheridan during CMS and state inspections, most recent first.
The facility did not ensure accurate and completed MDS assessments for multiple residents, as several admission, quarterly, annual, and significant change MDS assessments remained in “In Progress” status at the time of review. Medical record review and staff interview confirmed that these assessments had not been updated, and the DON acknowledged they were incomplete. This was inconsistent with the facility’s MDS 3.0 Completion policy, which requires comprehensive, accurate, standardized assessments of each resident’s functional capacity using the RAI.
A cognitively impaired, non-ambulatory, incontinent resident with a history of a Stage I pressure ulcer was left in a wheelchair for most of a day without being checked or changed, provided peri care, or transferred to bed, despite facility policies requiring a check-and-change strategy and pressure ulcer prevention measures. One CNA relied on the absence of odor instead of physically assessing the resident’s continence status or skin, did not follow the usual practice of laying the resident down in the afternoon to protect skin, and was unaware of the resident’s care plan or skin issues. Another staff member later reported that the resident had not been checked or changed all day, found the brief wet, observed a sore on the resident’s bottom that may have reopened, and reported the situation to the RN.
A resident with severe cognitive impairment, non-Alzheimer’s dementia, depression, incontinence, and total dependence for ADLs had care plans addressing mixed bladder incontinence and risk for impaired skin integrity that were not updated despite documented changes in condition. Progress notes described coccyx and sacral skin breakdown, application of barrier cream and Mepilex dressings, initiation of skin treatments in the TAR, and a Braden score of 13 with multiple risk factors, yet the care plans were not revised to reflect these developments. The DON confirmed that the care plans had not been updated, contrary to facility policy requiring interdisciplinary review and revision after assessments.
A resident with moderate cognitive impairment and mobility needs fell in the bathroom after waiting an extended period for staff assistance, as the emergency call light was not answered for over 30 minutes. The resident sustained a head injury and later died from a subdural hematoma. Staff interviews and records indicated previous delays in call light response, and the call light system did not distinguish between emergency and regular calls, contributing to the delayed response.
A resident with moderate cognitive impairment and multiple diagnoses experienced severe weight loss due to the facility's failure to provide adequate nutritional support. Despite being on a fortified diet with snacks, the resident was not offered snacks during extended periods at the dining table, and the care plan did not adequately address the need for frequent feedings. The dietitian confirmed that offering snacks was not documented in the resident's medical record, contributing to the resident's severe weight loss.
The facility did not have a qualified infection preventionist to manage the infection prevention and control program. The administrator was temporarily handling the responsibilities with help from the hospital, but no staff member had the necessary specialized training. The facility had 28 residents at the time.
The facility did not implement an antibiotic stewardship program, as shown by the absence of monitoring and review of antibiotic use. A resident was prescribed Cephalexin daily for infection management without a stop date or documented physician rationale for long-term use, and staff confirmed that no review process was in place despite facility policy assigning this responsibility to the Infection Control Committee and Infection Preventionist.
The facility failed to maintain resident dignity and privacy when CNAs discussed health information loudly in front of others. Observations showed CNAs asking residents about personal health matters and discussing resident care details audibly across the room. The administrator and DON acknowledged this was inappropriate and against facility policy, which requires confidential information to be protected and discussed privately.
The facility failed to provide adequate resident choice of activities in three of four cottages, leading to deficiencies in meeting residents' needs. Observations showed residents, including those with cognitive impairments, were not consistently engaged in scheduled activities, often left idle or alone. Staff interviews revealed insufficient staffing levels to support expected activity engagement, highlighting a gap between policy and practice.
A facility failed to provide adequate staffing in one of its cottages, affecting the care of a resident with severe dementia who required significant supervision. Observations and interviews revealed that the cottage was understaffed, with only one CNA, a patient care tech, and an RN on duty. The resident's behaviors, such as wandering and agitation, required one-to-one supervision, which was not consistently available, impacting the care of other residents as well.
The facility failed to document the education, offer, refusal, or receipt of influenza and pneumococcal immunizations for several residents. A review of medical records showed no evidence of required documentation for these vaccinations, and interviews with the administrator and DON confirmed the lack of evidence. The facility's policy requires such documentation, but it was not followed, resulting in the deficiency.
A resident with severe cognitive impairment due to dementia exhibited behaviors such as agitation and wandering, which were not adequately managed by the facility. Observations and progress notes indicated a lack of sufficient supervision and engagement in activities, with staff struggling to redirect the resident effectively. The facility was understaffed, and the activities director rarely engaged with residents, leading to unmet needs in dementia care.
A resident was prescribed Cephalexin 250 mg daily for infection management without a stop date or documented physician rationale for long-term use. The facility's Antibiotic Stewardship policy, which requires evidence-based antibiotic use, was not adhered to, as confirmed by the DON and administrator.
The facility failed to serve palatable food when a lunch meal of Creamy Chicken and [NAME] Soup was observed to have a thick, clay-like texture with no visible fluid. A resident noted the soup was too thick to eat, and another expressed dissatisfaction. The dietitian confirmed the soup was improperly prepared, lacking the necessary broth as per the recipe.
The facility did not check the CNA abuse registry before allowing four CNAs to have resident contact, despite having active Wyoming certifications. Human resources staff confirmed they were unaware of the requirement to check the state CNA abuse registry.
The facility failed to ensure a safe and functional environment in three cottages, leading to significant issues for residents, including extreme room temperatures and smoking heaters. One resident was hospitalized for rehydration and suspected pneumonia due to an overheated room. The maintenance director confirmed ongoing HVAC issues, with plans to upgrade the system but no immediate resolution.
The facility failed to provide sufficient nursing staff, leading to safety concerns for residents with severe cognitive impairments. A resident with a history of wandering was found outside the facility multiple times, and staff struggled to manage the situation due to inadequate staffing. Another resident was also found outside, highlighting the facility's staffing challenges. The resignation of nine CNAs and excessive overtime further exacerbated the issue, impacting the facility's ability to meet residents' needs.
The facility failed to appoint a licensed Nursing Home Administrator as required by Wyoming regulations. The CEO was acting as the administrator without a license since February 2023, as confirmed by interviews and documentation. The board only recently became aware of this regulatory requirement.
A resident with a pulmonary disease experienced issues with their CPAP mask, causing eye irritation. Despite being cognitively intact and reporting the problem to the former DON for three months, no action was taken. The resident was advised by the SW to contact the regional ombudsman and was given the CPAP service contact number, but the facility needed to arrange a consult with a CPAP representative, which was delayed until the current DON intervened.
The facility failed to post complete 24/7 nursing staff information, missing details such as elder census and actual hours worked by CNAs, RNs, and LPNs on multiple days across different cottages. The DON confirmed the postings were incomplete.
Incomplete and Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed and accurate for three of four sampled residents reviewed for MDS discrepancies. For one resident, both the admission and quarterly MDS assessments remained in “In Progress” status as of the survey review. For a second resident, the annual MDS assessment and a significant change MDS assessment were also found in “In Progress” status. For a third resident, both the admission and quarterly MDS assessments were likewise in “In Progress” status. Medical record review and staff interview confirmed that these MDS assessments had not been updated, and the DON acknowledged that the assessments were incomplete. Facility policy on MDS 3.0 Completion, as provided by the DON, states that according to federal regulations the facility must conduct initially and periodically a comprehensive, accurate, and standardized assessment of each resident’s functional capacity using the RAI specified by the state. These findings show that required MDS assessments for multiple residents were not finalized as completed assessments in accordance with the facility’s own policy and federal requirements, resulting in inaccurate or incomplete resident assessments at the time of survey review.
Neglect of Incontinent, Non-Ambulatory Resident’s Skin and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired, non-ambulatory, incontinent resident from neglect by not providing necessary incontinence care, repositioning, and monitoring throughout a day. The resident had severely impaired cognitive skills, non-Alzheimer’s dementia, depression, was dependent for ADLs, and had a history of a Stage I pressure ulcer with a pressure-relieving mattress in place. On the day in question, a CNA got the resident up around late morning and, with assistance from another CNA, transferred the resident to a wheelchair for lunch. The resident ate little and was typically given a nutritional shake. One CNA reported that another CNA did not know how to make the shake and asked a third CNA to prepare it; another CNA stated she periodically gave the shake throughout the day. The resident remained seated in the wheelchair at the end of the table after the noon meal and was not moved out of the wheelchair or laid down in the afternoon as was commonly done to protect the resident’s skin. According to staff interviews, the CNA primarily responsible for the resident that day did not check or change the resident’s brief, did not provide peri care, and did not transfer the resident to bed before the end of her shift, relying instead on the absence of odor as an indicator that care was not needed. Another staff member, who was functioning as a patient care tech and not yet allowed to provide direct care independently, reported that by the time evening staff arrived, the resident had not been checked or changed all day, and she observed a sore on the resident’s bottom that may have reopened after sitting in a wet brief. The evening CNA and this staff member then changed a wet brief and provided an oral nutritional supplement, and the condition was reported to the RN. The Social Services Director confirmed that the CNA had stated she did not check the resident because she did not smell anything, despite facility policies requiring a check-and-change strategy for severely cognitively impaired, incontinent residents and a pressure ulcer prevention program focused on minimizing moisture exposure and redistributing pressure.
Failure to Update Care Plan After Skin Breakdown and Changing Risk Status
Penalty
Summary
The facility failed to ensure a resident’s care plans were updated to reflect changes in condition and new clinical findings. The resident had severely impaired cognitive skills and diagnoses including non-Alzheimer’s dementia and depression, and was incontinent, non-ambulatory, and dependent on staff for ADLs. A quarterly MDS documented these conditions, and the facility’s incident tracking log showed an alleged incident of neglect involving this resident on 12/27/25. The resident’s care plan initiated on 12/5/23 addressed mixed bladder incontinence with goals related to maintaining dignity and remaining free from skin breakdown due to incontinence and brief use, and this care plan was last revised on 11/19/24. Another care plan initiated on 3/4/24 identified the resident as at risk for impaired skin integrity, but there were no further updates to this care plan. Subsequent clinical documentation showed clear changes in the resident’s skin condition that were not incorporated into the care plans. A progress note dated 11/15/25 described the coccyx area as showing signs of breakdown, starting to open and red, with barrier cream and a silicone border Mepilex dressing applied and skin treatment orders initiated in the TAR. A progress note dated 11/18/25 documented a Braden score of 13 with detailed risk factors, including very moist skin, chairfast activity level, very limited ability to change position, adequate nutrition, and friction and shear problems. Another progress note dated 12/3/25 recorded an opening on the sacral area and application of a new Mepilex dressing. Despite these documented changes and the facility policy requiring comprehensive care plans to be reviewed and revised by the interdisciplinary team at least after each comprehensive and quarterly MDS assessment, the DON confirmed that the resident’s care plans had not been updated.
Failure to Provide Adequate Supervision and Timely Call Light Response Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent accidents for a resident with moderate cognitive impairment and progressive neurological conditions. The resident required partial to moderate assistance with mobility and activities of daily living, including transfers and toileting. On the day of the incident, the resident fell in the bathroom after attempting to use the toilet without assistance, resulting in a head injury and an abrasion to the left elbow. The fall was unwitnessed, and the resident was found on the floor by a CNA after the emergency bathroom call light had been activated for an extended period. Medical record review and staff interviews revealed that the resident had previously reported delays in staff response to call lights, sometimes waiting over 20 minutes, which led the resident to attempt bathroom use independently. On the day of the fall, the emergency bathroom call light was activated and remained unanswered for 36 minutes before being cancelled. The CNA who found the resident was unfamiliar with the resident and had been told the resident was fairly independent. The RN who responded noted that the resident did not normally use the call light and that no alarms were heard at the time of the incident. Further investigation showed that the call light system in use at the time did not differentiate between emergency and regular calls, as both had the same tone, making it difficult for staff to prioritize responses. The administrator confirmed that staff were expected to answer call lights immediately, but the system's limitations and staff unfamiliarity contributed to the delayed response. As a result of the fall, the resident developed a subdural hematoma and subsequently passed away.
Failure to Provide Adequate Nutritional Support
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident with moderate cognitive impairment and multiple diagnoses, including dementia and chronic obstructive pulmonary disease. The resident was on a regular fortified low sodium diet with snacks, as per physician orders. However, the resident experienced a severe weight loss of 7.34% in one month, dropping from 88.5 lbs to 82.0 lbs. Observations revealed that the resident, who appeared very thin with hollow cheeks and temples, was not offered snacks during extended periods at the dining table, despite the care plan indicating the need for small, frequent feedings and snacks. The dietitian confirmed that offering snacks was not a documented task in the resident's medical record, although it was expected that staff offer snacks, particularly between lunch and dinner. The facility's policy on weight assessment and intervention indicated that a weight loss greater than 5% in one month is severe and requires a multidisciplinary care plan. However, the resident's care plan did not adequately address the need for snacks, and there was no documentation of snacks being offered or accepted over a month-long period, contributing to the resident's severe weight loss.
Lack of Qualified Infection Preventionist
Penalty
Summary
The facility failed to ensure a qualified infection preventionist was designated to oversee the infection prevention and control program. During an interview with the facility administrator, it was revealed that the position of infection preventionist was vacant. The administrator was managing the program with assistance from the hospital, but confirmed that no staff member had completed specialized training in infection prevention and control. The facility had a census of 28 residents at the time of the survey.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program as required, as evidenced by the lack of monitoring and review of antibiotic use. Medical record review for one resident revealed a physician order for Cephalexin 250 mg daily for infection management, initiated without a stop date and lacking documented physician rationale for long-term use, despite the resident having no current symptoms and the antibiotic being prescribed for prophylaxis. Interviews with the DON and administrator confirmed that no rationale was provided for the extended antibiotic therapy and that the facility had not established a program to review antibiotic usage. Additionally, review of the facility's policy indicated that the Infection Control Committee and Infection Preventionist were responsible for monitoring antibiotic use, but this process was not being followed.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity in one of the resident cottages. During observations, it was noted that CNAs were discussing resident health information at a volume that could be heard across the room, compromising the privacy and dignity of the residents. On one occasion, a CNA asked a resident about their bowel movements in front of others, and another CNA discussed the frequency of changing another resident. On a separate occasion, CNAs discussed a resident's health information loudly from across the room. Interviews with the administrator and DON confirmed that such discussions were inappropriate and not in line with the facility's policy on maintaining dignity and confidentiality. The facility's policy emphasized that confidential clinical information should be protected and discussed outside the hearing range of residents and the public.
Deficiency in Resident Activity Engagement
Penalty
Summary
The facility failed to provide resident choice of activities for three of four resident cottages, leading to deficiencies in meeting the residents' needs. Observations and interviews revealed that scheduled activities were not consistently offered, and residents were often left without engagement. For instance, resident #6, who was cognitively intact and had a preference for group and individual activities, was not invited to participate in a card game and spent most of the time alone in the room. The activity participation record showed limited engagement in activities, with the resident attending only a few social events. Resident #11, with severe cognitive impairment, was observed to have limited participation in activities despite a care plan that emphasized the importance of group activities and personal interests like painting. The resident was seen sitting idle for extended periods, and the activity participation record indicated minimal involvement in activities beyond basic social interactions. Similarly, resident #20, also with severe cognitive impairment, was not included in group activities like Domino's and was observed wandering the cottage with minimal staff interaction, highlighting a lack of personalized engagement. Interviews with staff, including the activities director, revealed that the facility's staffing levels were insufficient to support the expected level of activity engagement. The activities director acknowledged that staff were expected to perform activities but admitted that the current staffing levels made it challenging to meet these expectations. The facility's policy on elder preference of activities emphasized the importance of resident choice, yet the observations and interviews indicated a significant gap between policy and practice, resulting in unmet resident needs for meaningful activities.
Inadequate Staffing in Cottage Leads to Deficiency
Penalty
Summary
The facility failed to ensure adequate staffing in one of its cottages, which had a census of nine residents. The deficiency was identified through observations, interviews, and a review of facility staffing. A resident with severe cognitive impairment and a history of dementia exhibited behaviors such as wandering, agitation, and attempts to leave the facility unattended. These behaviors required significant staff intervention, including redirection and one-to-one supervision, which was not consistently available. Observations on multiple occasions showed the resident attempting to exit the facility and interacting with other residents in a manner that caused distress. Staff interviews revealed that the cottage was understaffed, with only one CNA, a patient care tech, and an RN on duty at the time of the survey. The patient care tech, who was still in training, was instructed to perform resident care tasks despite not being fully qualified, highlighting the staffing inadequacies. Interviews with other residents and their representatives confirmed the perception of insufficient staffing, which impacted the care provided to all residents in the cottage. The lack of adequate staff prevented the completion of essential duties such as showers and activities, further exacerbating the situation. The facility's failure to provide sufficient staffing to meet the needs of its residents, particularly those with high care requirements, was a significant factor in the identified deficiency.
Failure to Document Immunization Education and Administration
Penalty
Summary
The facility failed to document the education, offer, refusal, or receipt of influenza and pneumococcal immunizations for four out of six sampled residents. Specifically, the immunization records for these residents lacked evidence of education about the benefits and potential side effects of the vaccines, as well as documentation of whether the vaccines were offered, refused, or administered. This deficiency was identified through a review of the medical records of residents #12, #14, #24, and #28, which showed no documentation of the required information for influenza, pneumococcal, and in some cases, COVID-19 vaccinations. An interview with the facility's administrator and director of nursing confirmed that the facility did not have evidence that the immunizations were offered or provided to the affected residents. The facility's policy, last updated in March 2022, mandates that residents or their legal representatives be educated about the vaccinations and that this education, along with any refusal or administration of the vaccines, be documented in the medical records. However, this policy was not followed for the residents in question, leading to the identified deficiency.
Inadequate Dementia Care and Supervision
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with severe cognitive impairment due to dementia, as evidenced by multiple observations and progress notes. The resident, who had a BIMS score of 0 indicating severe cognitive impairment, was noted to have behaviors such as verbal aggression, agitation, wandering, and attempts to leave the facility unattended. Despite these behaviors being documented in the care plan, the facility did not ensure adequate supervision or engagement in activities that could help manage these behaviors. Observations showed the resident ambulating independently and attempting to exit the facility, with staff struggling to redirect him/her effectively. Progress notes revealed a pattern of restlessness, agitation, and difficulty in redirecting the resident, with PRN Haldol being administered without noted effectiveness. The resident exhibited behaviors such as pacing, moving objects, and attempting to leave the facility, which were not adequately managed by the staff. Interviews with staff indicated that the cottage was understaffed, lacking a 1:1 staff member to provide necessary redirection and supervision for the resident. Additionally, the activities director rarely engaged with the residents, leading to a lack of structured activities that could have potentially calmed the resident and reduced wandering. The resident's representative expressed concerns about the lack of engagement in activities and the staff's approach to dementia care, indicating that staff were not adequately trained to handle the resident's needs. The facility's failure to provide sufficient staffing and activities, along with inadequate staff training, contributed to the resident's unmet needs and the deficiency in providing appropriate dementia care.
Failure to Ensure Drug Regimen Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. A review of the physician orders revealed that a resident had been prescribed Cephalexin 250 mg daily for infection management without a specified stop date. This prescription was initially ordered on 9/27/24, following a hospital discharge note from 9/26/24, which indicated the resident had a recurrent infection but no current symptoms. The antibiotic was intended for prophylaxis, yet there was no documented physician rationale for its long-term use. An interview with the Director of Nursing (DON) and the administrator confirmed that the physician had not provided a rationale for the prolonged antibiotic use. Additionally, the facility's policy on Antibiotic Stewardship, last revised on 8/20/23, mandates that the Antibiotic Stewardship Committee supports and promotes antibiotic use protocols based on evidence appropriate for long-term care residents. However, this protocol was not followed in the case of the resident in question.
Failure to Serve Palatable and Properly Prepared Food
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and met the expected consistency. During an observation, the lunch meal of Creamy Chicken and [NAME] Soup was noted to have a thick texture, resembling clay, with no visible fluid. A resident commented that while the flavor was acceptable, the soup was too thick to eat, and another resident expressed dissatisfaction with the meal. The dietitian confirmed that the soup was thicker than intended due to incorrect preparation by a staff member the previous night. The recipe review indicated that the soup should have contained visible liquid broth, which was missing in the served meal.
Failure to Check CNA Abuse Registry Before Resident Contact
Penalty
Summary
The facility failed to ensure that the Certified Nursing Assistant (CNA) abuse registry was checked prior to resident contact for four CNAs. Employee file reviews for CNAs #6, #7, #8, and #9 revealed that although each had an active Wyoming certification, there was no evidence that the abuse registry was checked before they had contact with residents. An interview with two human resources staff members confirmed that the facility only checked for abuse through the department of family services and was unaware of the requirement to check the state CNA abuse registry prior to resident contact.
Facility Fails to Ensure Safe and Functional Environment in Cottages
Penalty
Summary
The facility failed to ensure a safe and functional environment in three of its cottages, leading to significant issues for residents. In one incident, a staff member found a resident's room extremely hot with a thermostat reading of 97 degrees Fahrenheit, despite being set to 71 degrees. The resident was lethargic, flushed, and had a temperature of 100.4 degrees Fahrenheit, necessitating hospital transfer for intravenous rehydration and further evaluation. The resident was later diagnosed with suspected pneumonia and ordered antibiotic therapy. Another resident reported having to be moved due to a smoking heater in their room, and issues with inconsistent room temperatures were noted by both residents and staff. The maintenance director confirmed ongoing problems with the heating and air conditioning systems in the cottages, with administration aware and working on the issues. The maintenance director revealed that the baseboard heat in the cottages had been shut off, and central heating and air conditioning were being used to regulate temperatures. An electrician tested the bathroom fan in one room but could not identify the root cause of the temperature increase. The facility had previously replaced a relay in a baseboard heater due to smoke and smell issues, and the long-term plan was to remove all 48 baseboard heaters and upgrade the HVAC system. Despite these efforts, the facility could not ensure that similar events would not occur again, as evidenced by the inability to find a malfunction in the heating lamp and the decision to turn the breaker back on while the resident remained in the room.
Staffing Deficiencies Lead to Resident Safety Concerns
Penalty
Summary
The facility failed to ensure sufficient nursing staff to provide necessary care and safety for residents, particularly in [NAME] Cottage. Elder #1, diagnosed with severe cognitive impairment, exhibited wandering and elopement behaviors. Multiple incidents were reported where the elder attempted to leave the facility unattended, and staff struggled to manage these behaviors due to inadequate staffing. On several occasions, the elder was found outside the cottage, and staff were unable to redirect or manage the situation effectively. The staffing levels were insufficient, with only one CNA and half a nurse scheduled during night shifts, which contributed to the inability to monitor and care for the elder adequately. In another instance, Elder #5, also with severe cognitive impairment, was found outside the facility on two separate occasions. The staffing records showed inconsistencies and gaps, with many days left undocumented, indicating potential understaffing. Observations revealed that staff were often unavailable to assist residents promptly, leading to delays in care and supervision. Interviews with staff highlighted the challenges faced due to insufficient staffing, with CNAs expressing concerns about the workload and the impact on their ability to provide adequate care. The general facility faced significant staffing challenges, exacerbated by the resignation of nine CNAs in February, which was linked to management issues. The facility's payroll records showed CNAs working excessive hours, indicating a reliance on overtime to cover staffing shortages. The human resources director confirmed the facility had several CNA openings and acknowledged scheduling errors. These staffing deficiencies directly impacted the facility's ability to meet the needs of its residents, compromising their safety and well-being.
Failure to Appoint Licensed Nursing Home Administrator
Penalty
Summary
The facility failed to appoint a licensed Nursing Home Administrator (NHA) as required by the Wyoming Board of Nursing Home Administrators. The Wyoming Nursing Home Administrators Chapter 2 Rules, effective since December 19, 2019, mandate that no individual can perform functions specific to a Nursing Home Administrator without being licensed by the Board. Despite this requirement, the facility's CEO was named as the new Administrator/Director on a Healthcare Facility Change in Personnel form dated February 13, 2023, without a Wyoming professional license number. The facility assessment updated on January 29, 2024, listed a CEO on staff but did not indicate the employment of a licensed NHA. Interviews conducted during the survey revealed further deficiencies. The CEO confirmed that she held the title of CEO and did not possess a license from the Wyoming Board of Nursing Home Administrators. Additionally, the facility was unable to provide a job description for either the CEO or an NHA. The president of the Board of Directors acknowledged that the board had only recently become aware of the regulatory requirement and that the CEO had been acting as the nursing home administrator since February 2023. These findings indicate a clear violation of the licensure requirements for nursing home administrators in Wyoming.
Failure to Address CPAP Mask Issues for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with a diagnosis of an unspecified pulmonary disease, such as asthma, chronic obstructive pulmonary disease, or chronic lung disease. The resident, who was cognitively intact with a BIMS score of 15 out of 15, reported issues with their CPAP mask not fitting properly, causing eye irritation. Despite raising these concerns with the former Director of Nursing (DON) over a period of approximately three months, no action was taken. The resident attempted to contact the respiratory service company directly but was informed that the inquiry had to be made by the DON. A communication note from 2/26/24 indicated that the resident was advised by the Social Worker (SW) to contact the regional ombudsman and was provided with the CPAP service contact number. However, the facility was responsible for setting up a consult with a CPAP representative, which had not been done until the current DON called the representative on 3/19/24.
Incomplete Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the posted 24/7 nursing staff information included all required details. A review of the daily nurse staffing information for Founders Cottage, [NAME] Cottage, and another [NAME] Cottage revealed that on multiple days, the postings did not include the elder census, the total number, and actual hours worked by Certified Nursing Assistants (CNAs), Registered Nurses (RNs), and Licensed Practical Nurses (LPNs) per shift. Specifically, Founders Cottage had 14 out of 47 days with missing information, [NAME] Cottage had 14 out of 46 days, and the other [NAME] Cottage had 29 out of 47 days with incomplete postings. An interview with the Director of Nursing (DON) confirmed the incompleteness of the daily nurse staffing data.
Latest citations in Wyoming
A facility failed to keep residents’ personal and medical records secure and confidential. Medical record review showed hospice notes were entered directly into the EMR for three residents, and the regional clinical director stated the hospice previously used was given full access to the EMR for all residents. The Resident Rights policy stated residents have a right to secure and confidential personal and medical records.
Failure to Offer Choice of Hospice Provider: The facility did not ensure that 3 residents receiving hospice services were offered a choice of hospice provider. Medical record review showed no evidence that the residents were given provider choice, and an RCD confirmed that prior to the operator transition, hospice residents were not given a choice. The facility's Resident Rights policy states residents have the right to choose health care and providers of health care services.
Failure to Assess and Document Changes in Condition: A resident with repeated falls, hypoxia, lethargy, and later hospital transfers had multiple episodes where assessments, vital signs, or follow-up documentation were missing or delayed. Another resident with COPD and impaired gas exchange was observed in respiratory distress without oxygen and was later transferred for respiratory failure, with no transfer documentation on the progress notes. A third resident with dementia and a history of falls had incomplete post-fall assessments and was later sent to the hospital after additional falls and pain. A fourth resident with a Foley catheter had cloudy, low, and absent output, pain, and family requests for transfer; the catheter was later found to have caused traumatic injury and hematuria.
Opened medications in two medication fridges were found without required opened-on or discard dates. An Ozempic pen in one fridge and an opened Tubersol vial plus an opened Ativan oral solution in another fridge were all in use but unlabeled, and staff confirmed the missing dates. The DON stated she expected in-use multi-dose vials to have an opened-on or discard-by date, and manufacturer guidance reviewed for these medications specified discard timelines after opening.
A facility failed to ensure hospice services met professional standards for 3 sampled residents. Medical record review showed each resident was receiving hospice services, but none of the records contained a physician order for hospice referral or eval. An RCD confirmed that residents placed on hospice did not receive a physician order for eval and that the hospice used at the time had access to all resident medical records.
Infection control was not maintained during meal service and resident care. A CNA touched hair, clothing, and other surfaces while handling meal tickets, food, and drink cups without hand hygiene, including placing chips on a resident’s burger and touching cup rims. Staff also left visibly soiled linens in place for a resident with bowel incontinence, and oxygen cannulas/tubing for multiple residents were found on the floor or unlabeled, with one cannula picked up from the floor and placed on a resident.
A facility failed to ensure pneumococcal immunization status was assessed for 5 of 5 sampled residents. Medical record review showed no evidence that PCV had been assessed or offered, and the IP confirmed there was no documentation of pneumococcal vaccination status. The facility reported its immunization process tracked vaccines on admission and documented annual COVID and influenza vaccines, but the pneumococcal audit had been delayed because records could not be accessed.
Failure to timely report alleged verbal abuse: A volunteer reported that an activities staff member yelled at a resident during bingo, told the resident to stop interrupting, and also yelled at the volunteer when she intervened. The resident later described the staff member as rude and said the comment made him/her angry. Survey review found no evidence the allegation was reported, and the RCD confirmed the facility had no evidence of reporting despite policy requiring immediate reporting of abuse allegations.
Failure to Investigate Allegation of Verbal Abuse: A volunteer reported that an activities staff member yelled at a resident during bingo and then yelled at the volunteer when she intervened. Interviews with the resident and volunteer confirmed the staff member spoke rudely and loudly to the resident, and the regional clinical director confirmed there was no evidence the verbal abuse allegation was reported or investigated.
Failure to Allow Return After Hospital Transfer: A resident was transferred to the ER for altered mental status and increased confusion, but the facility did not provide a transfer/discharge notice and did not allow the resident to return after the acute hospitalization. The DON stated the decision not to permit return was financial, while the business office manager believed it was due to insufficient staffing. The facility policy stated residents transferred to acute care will be permitted to return upon discharge, and not permitting return constitutes a discharge.
Failure to Protect Confidential Medical Records
Penalty
Summary
The facility failed to ensure residents’ personal and medical records remained secure and confidential. Medical record review showed that resident #26 received hospice services beginning on 1/2/26, resident #83 received hospice services beginning on 1/21/26, and resident #84 received hospice services beginning on 2/5/26, and the hospice provided documented notes directly into the electronic medical record system. During interview on 5/6/26 at 12:44 PM, the regional clinical director stated the only hospice used prior to a change in operator was given full access to the electronic medical record for all residents. Review of the facility’s Resident Rights policy stated residents have a right to privacy and confidentiality of personal and medical records and the right to secure and confidential records.
Failure to Offer Choice of Hospice Provider
Penalty
Summary
The facility failed to ensure residents' right to choose their health care providers for 3 of 12 sampled residents reviewed for hospice services. Resident #26 began receiving hospice services on 1/2/26, resident #83 began receiving hospice services on 1/21/26, and resident #84 began receiving hospice services on 2/5/26, but the medical record review showed no evidence that any of these residents were offered a choice in hospice provider. During an interview on 5/6/26 at 12:44 PM, the regional clinical director confirmed that prior to the operator transition, residents on hospice were not given a choice for hospice provider. The facility's Resident Rights policy, last revised on 6/10/25, states that the resident has the right to choose health care and providers of health care services consistent with his or her interests, assessments, and plan of care.
Failure to Assess and Document Changes in Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for four residents who experienced changes in condition. For resident #1, the record showed multiple episodes where the resident was found after falls, had low oxygen saturations, became lethargic, or was unresponsive, yet there was no evidence of timely assessments, vital signs, or follow-up documentation at several of those events. The record also showed a late entry note for a 3/5/26 incident was added 62 days after the event. The resident was later transferred to the hospital for respiratory failure, pneumonia, acute heart failure, dry gangrene, hyponatremia, metabolic encephalopathy, pulmonary edema, critical electrolyte abnormalities, atrial fibrillation with RVR, and acute kidney injury. For resident #69, the resident had diagnoses including chronic myeloid leukemia, CAD, seizure disorder, traumatic brain injury, and COPD, and the care plan addressed impaired gas exchange. On 5/4/26, the resident was observed sitting on the edge of the bed with a respiratory rate of 30-40 breaths per minute, grey pallor, and no oxygen in place. The resident was later sent to the hospital for respiratory failure, but the progress notes for the transfer did not show documentation on 5/5/26. A later facility note stated the resident had been found with oxygen saturation of 60% on 4 lpm NC, difficulty breathing, and lethargy, and the LPN reported she had been asked to come in on her day off to document the assessment and transfer. For resident #81, who had severe cognitive impairment, dementia, COPD, atrial fibrillation, CAD, diabetes, and a history of falls, the record showed repeated falls and incomplete assessments. After a fall on 4/20/26, the assessment section was left blank. Another note dated 4/23/26 documented pain, confusion, and unsteadiness but stated there were no safety risks. After a fall on 4/25/26, staff documented vital signs and a normal assessment but did not know whether the resident hit his/her head, and there was no evidence of follow-up assessments. After a fall on 4/30/26, the resident was found on the floor with pain, and the interdisciplinary review identified impaired cognition, weakness, and self-transfers as the root cause, with a new skin tear noted. The resident's representative reported the resident was in significant pain, not at baseline, disheveled, saturated with urine, had neck swelling, and was missing a pain patch, and stated no vital signs or assessment had been done before the resident was sent to the hospital. For resident #6, who had moderate cognitive impairment, cancer, CAD, heart failure, renal disease, dementia, and an indwelling catheter, the care plan identified UTI risk related to the Foley catheter. After a recent hospitalization for sepsis related to UTI/prostate cancer, the record showed thick cloudy catheter output, complaints of pain, and periods of no catheter output. The resident's family repeatedly requested hospital transfer, and the catheter was changed after the resident had no output since the prior shift; the catheter then drained but had bloody urine. The resident later had cloudy grayish-yellow urine, was not getting up for breakfast, and was transferred to the ED. The ER report stated the Foley had caused traumatic injury and hematuria because the balloon was inflated in the prostatic urethra, and the resident also had AKI with creatinine elevated above baseline. The DON stated she expected transfer documentation to include resident condition, vital signs, notifications, and immediate or within-24-hour documentation, and confirmed that only vital signs were completed and ongoing assessment was not completed as expected.
Medication Labeling Deficiency in Two Medication Fridges
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with accepted professional principles because opened medications in two medication refrigerators did not have an opened-on or discard date. During observation in the Rock Creek medication fridge, an Ozempic 8 mg/3 ml pen was found with no opened-on or discard date. MA-C #1 confirmed the Ozempic pen had been opened and used the day before and that no date had been written on it. In the secure unit fridge, an opened Tubersol vial and an opened Ativan oral solution 2 mg/ml were observed without opened-on or discard dates. LPN #2 confirmed both medications were in use and that neither had the required dates. The DON stated she expected an opened-on or discard-by date to be written on in-use multi-dose vials. Manufacturer instructions reviewed for Ozempic, oral liquid Lorazepam, and Tubersol specified time limits for use after opening, and the facility policy required multi-use vials to include the date initially opened or accessed.
Missing Physician Orders for Hospice Referrals
Penalty
Summary
The facility failed to ensure hospice services met professional standards for 3 of 12 sampled residents. Medical record review showed that resident #7 began receiving hospice services on 3/31/26, resident #83 began receiving hospice services on 1/21/26, and resident #84 began receiving hospice services on 2/5/26, but none of the three records contained evidence of a physician order for a hospice referral or evaluation. During interview on 5/6/26 at 12:44 PM, the regional clinical director confirmed that residents placed on hospice did not receive a physician order for evaluation and that the hospice used at that time was given access to the medical record for all residents.
Infection Control Lapses During Dining, Linen Care, and Oxygen Equipment Handling
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained for resident care and meal service. During dining room observation, a CNA touched his hair, handled resident meal tickets, and repeatedly handled resident food and drink items with exposed hands without performing hand hygiene between tasks. The CNA placed a bag of chips on top of a resident’s hamburger, touched the top bun to apply jelly, handled drink cups by the rims, and continued passing trays after touching his pants, hair, and other surfaces. The infection preventionist and DON confirmed staff were expected to perform hand hygiene after touching hair, skin, or clothing and that the CNA should not have touched resident meal items without hand hygiene. The facility also failed to manage soiled linens and oxygen equipment for residents with visible contamination or tubing on the floor. One resident had linens visibly soiled with bowel movement incontinence, yet the blanket was pulled over the sheets, the soiled linen remained visible during later observations, the resident lay on top of an oxygen cannula on the soiled sheets, and housekeeping picked up the cannula from the floor and placed it on the resident. Two other residents had nasal cannulas or oxygen tubing on the floor or unlabeled, including tubing dated 4/19/26 and tubing labeled 5/3/26 that remained on the floor during repeated observations. The IP confirmed oxygen tubing should be changed and labeled weekly and as needed or when visibly soiled, that cannulas found on the floor should not be used on residents, and that soiled linens should be changed immediately.
Failure to Assess and Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure residents were immunized for pneumococcal disease for 5 of 5 sampled residents (#66, #69, #1, #33, and #4) reviewed for current vaccination status. Medical record review showed no pneumococcal conjugate vaccine had been assessed or offered for these residents. The infection preventionist confirmed there was no evidence of pneumococcal vaccination status, and also stated the facility’s immunization process assessed and tracked vaccines on admission, with annual COVID and influenza vaccines offered and documented, but that the pneumococcal vaccine audit had been delayed because records could not be accessed. CDC guidance reviewed by surveyors indicated that adults age 19 years or older with unknown or no prior PCV history should receive PCV15, PCV20, or PCV21.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse was reported timely for resident #55. A volunteer submitted a grievance stating that during bingo on 2/14/26, activities staff member #1 yelled at resident #55 after the resident called out bingo and told the resident to stop interrupting while she was talking. The volunteer reported that the staff member continued yelling for a couple of minutes, and when the volunteer intervened and told the staff member to stop yelling at the resident, the staff member yelled at the volunteer as well. The grievance also stated that two residents, including resident #55 and resident #66, reported that the activities staff member yells at them all the time and speaks to them the same way every time they play bingo. Resident #55 later stated that the issue involved the activities staff member being rude during bingo and saying, in a smart-ass way, "weren't you paying attention?" The resident said the comment made him/her angry and that [he/she] called the staff member names. The volunteer confirmed hearing the staff member speak loudly and rudely to the resident and then yell at the volunteer before storming off. Review of the state survey agency incident database showed no evidence the allegation was reported, and the regional clinical director confirmed the facility had no evidence the verbal abuse allegation was reported. The facility policy required alleged abuse to be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, immediately but no later than 2 hours when the allegation involved abuse or serious bodily injury.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse was thoroughly investigated for resident #55. A complaint/grievance form documented that a volunteer reported activities staff member #1 yelled at resident #55 during bingo after the resident called out bingo, and the volunteer stated the staff member continued yelling at the resident and then yelled at the volunteer when she intervened. The grievance also noted that two residents reported the activities staff member yelled at them all the time and spoke to them the same way during bingo. Interviews confirmed the incident involved rude and loud comments by the activities staff member toward resident #55 during bingo, including telling the resident to stop interrupting and making a smart-ass remark. Resident #55 stated the interaction upset him/her and that the staff member was later terminated. A volunteer corroborated hearing the staff member speak loudly and rudely to the resident and then yell at the volunteer. Review of the state survey agency incident database showed no evidence the allegation was reported, and the regional clinical director confirmed the facility had no evidence the verbal abuse allegation was investigated.
Failure to Allow Return After Hospital Transfer
Penalty
Summary
The facility failed to ensure resident #82 was allowed to return after an acute hospitalization. A progress note dated 3/11/26 at 8:33 PM documented that the resident was transferred to the hospital emergency room for altered mental status and increased confusion. The medical record showed no evidence that a transfer/discharge notice was provided at the time of transfer. A discharge MDS assessment showed the resident’s return to the facility was anticipated and that the discharge was unplanned, with a discharge status of Short-Term General Hospital (acute hospital, IPPS). Interviews confirmed the resident did not return to the facility after the hospital transfer. The DON stated on 5/7/26 at 9:45 AM that the decision not to allow the resident to return was financial, and also confirmed that no discharge notice was provided after transfer and that the facility did not assist in finding alternate placement. The business office manager stated on 5/7/26 at 10:54 AM that the resident was not allowed to return following the hospital transfer, although he believed the reason was insufficient staffing. The facility policy stated that residents transferred to acute care will be permitted to return upon discharge and that not permitting a resident to return following hospitalization constitutes a discharge.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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