Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 11, 2025
Visit Reason
A revisit survey was conducted on 12/11/2025 to verify correction of all previous deficiencies cited on 12/5/2025.
Findings
All previously cited deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 11, 2025
Visit Reason
A revisit survey was conducted on 12/11/25 for all previous deficiencies cited on 12/5/25.
Findings
All deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Routine
Census: 16
Deficiencies: 1
Dec 5, 2025
Visit Reason
A revisit survey was conducted from 11/14/25 through 12/5/25 to review previous deficiencies related to the facility's failure to have a licensed Nursing Home Administrator as required by Wyoming regulations.
Findings
The facility did not meet the licensure requirement for a Nursing Home Administrator. The current administrator was not licensed, and the facility lacked a licensed nursing home administrator at the time of the survey. The facility had a provisional Nursing Home Administrator licensee working through the administrator in training program, with plans for obtaining full licensure.
Deficiencies (1)
| Description |
|---|
| Failure to employ a qualified, licensed Nursing Home Administrator as required by Wyoming regulations. |
Report Facts
Census: 16
Inspection Report
Re-Inspection
Census: 16
Deficiencies: 1
Nov 14, 2025
Visit Reason
A revisit survey was conducted from 11/14/25 through 12/5/25 to verify correction of all previous deficiencies cited on 7/10/25.
Findings
The facility failed to have a licensed nursing home administrator as required by Wyoming state regulations. The current administrator, Eric S. Connell, holds a Nursing Home Administrator license and will serve as preceptor/trainer for another individual seeking licensure. The facility is working to obtain a temporary nursing home administrator license for the other individual and will continue monitoring to ensure compliance.
Deficiencies (1)
| Description |
|---|
| The facility must have a governing body or designated persons functioning as a governing body responsible for establishing and implementing policies regarding management and operation of the facility, including appointing a licensed nursing home administrator responsible for management and accountable to the governing body. |
Report Facts
Census: 16
Date survey completed: Dec 5, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric S. Connell | Nursing Home Administrator | Named as the current Nursing Home Administrator responsible for the facility |
| Jordan Collins | RN | Responsible for monitoring and verifying licensure status monthly |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 14, 2025
Visit Reason
A Life Safety Code and Emergency Preparedness revisit survey was conducted to verify correction of all previous deficiencies cited on 07/09/2025.
Findings
All previously cited deficiencies have been corrected, and the facility is now in compliance with 42 CFR 483.90 (Life Safety Code) and 42 CFR 483.73 (Emergency Preparedness).
Report Facts
Previous deficiency citation date: Jul 9, 2025
Inspection Report
Annual Inspection
Census: 18
Deficiencies: 2
Jul 10, 2025
Visit Reason
A licensure survey was conducted from July 7, 2025 through July 10, 2025 to assess compliance with Wyoming nursing care facility regulations.
Findings
The facility failed to employ a qualified nursing home administrator with an active license and failed to provide an ongoing program of meaningful activities tailored to resident preferences, with no activities offered for at least two weeks during the survey period.
Deficiencies (2)
| Description |
|---|
| Failure to employ a qualified nursing home administrator with an active license or provisional license. |
| Failure to ensure individual activities of preference were provided to residents, with no activities offered for at least two weeks. |
Report Facts
Census: 18
Activities scheduled: 34
Activities scheduled: 25
Activities performed: 2
Inspection Report
Annual Inspection
Census: 18
Deficiencies: 9
Jul 10, 2025
Visit Reason
A recertification survey was conducted from 7/7/25 through 7/10/25, including review of complaint intakes WY1902076, WY1902077, and WY1902078.
Findings
The facility was found deficient in multiple areas including failure to deliver mail on Saturdays, incomplete advance directives for residents, verbal abuse by a staff member, improper use of psychotropic medications, inadequate activities program and staffing, failure to verify nurse aide registry status, lack of a qualified nursing home administrator, and improper infection control practices.
Complaint Details
Complaint intakes WY1902076, WY1902077, and WY1902078 were reviewed during the survey. Issues included failure to deliver mail on weekends, incomplete advance directives, verbal abuse allegations, and other care concerns.
Severity Breakdown
SS = C: 2
SS = D: 4
SS = E: 3
SS = F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure mail was delivered to residents, including on Saturdays. | SS = C |
| Failure to ensure residents' right to elect cardiopulmonary resuscitation status for 2 residents. | SS = D |
| Failure to protect resident's right to be free from verbal abuse by a staff member. | SS = D |
| Failure to ensure PRN psychotropic medications were limited to 14 days or had documented rationale. | SS = D |
| Failure to provide individual activities meeting residents' interests and needs. | SS = E |
| Failure to ensure the activities program was directed by a qualified professional. | SS = E |
| Failure to verify nurse aide registry status for a CNA prior to resident contact. | SS = C |
| Failure to employ a qualified nursing home administrator with an active license. | SS = F |
| Failure to ensure proper infection control practices during perineal care and meal services. | SS = E |
Report Facts
Census: 18
Deficiency severity counts: 10
Resident sample size: 12
Resident sample size: 5
Activities scheduled: 34
Activities scheduled: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Assistant | Named in verbal abuse finding and subsequent suspension and termination. |
| CNA #3 | Certified Nursing Assistant | Named in failure to verify nurse aide registry prior to resident contact. |
| Director of Nursing | Director of Nursing | Involved in communication and follow-up related to mail delivery, advance directives, psychotropic medication use, and abuse training. |
| Activities Director | Activities Director | Named in findings related to inadequate activities program and lack of qualifications. |
| Facility Administrator | Chief Executive Officer | Named in finding related to lack of active nursing home administrator license. |
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