Compassionate, respectful, and attentive nursing and CNA care
Comfort-focused end-of-life support and pain-management attention
Strong rehabilitation, physical therapy, and occupational therapy
Welcoming family involvement, including visits, meals, and activities
Clean, bright, remodeled, and well-maintained rooms and common areas
Positive dining feedback, including healthy and enjoyable meals
Engaging activities and a home-like, resident-centered environment
Helpful administration and efficient admission and aftercare coordination
Responsive maintenance, laundry, and housekeeping services
Approachable leadership and organized facility operations
Regular family updates and support for student learning
Cons
Uneven responsiveness and follow-through on family-raised concerns
Staffing-capacity concerns affecting timely personal care and individualized mobility support
Specialized wound-care equipment readiness and coordination concerns
Summary of reviews
Feedback about Rocky Mountain Care - Evanston is predominantly positive. Families and residents frequently describe staff as kind, attentive, professional, and respectful, with care that feels personal and welcoming. Several accounts praise support during rehabilitation and extended stays, while families facing end-of-life care describe staff helping them understand care steps, providing comfort-focused attention, and accommodating extended bedside visits. One resident also praised the nursing team’s attention to cleanliness and safety.
Rehabilitation is a notable strength in the feedback. Reviewers speak positively about physical and occupational therapy, and families describe staff helping coordinate transitions into the facility and home after a stay. Administrative staff are often characterized as helpful with admissions, paperwork, questions, and family communication. Families also mention quarterly updates, and one reviewer specifically praised the facility’s support for visiting nursing students.
The building is commonly described as clean, bright, remodeled, and well maintained. Reviewers also praise a relaxed, home-like atmosphere and staff efforts to treat residents as individuals. Dining feedback is positive, including comments about healthy, enjoyable food and a good kitchen team. Activities are described as fun and meaningful, and families value being able to join residents for meals and activities. Laundry, maintenance, and housekeeping also receive positive mentions; one family appreciated that a dog could visit.
A few accounts raise concerns that warrant follow-up. One family described staff as overwhelmed, difficulty getting a response from nursing administration, delays in personal care, and limited mobility accommodations for a resident using oxygen. Another family reported problems with the facility’s readiness and ability to operate specialized wound-care equipment, along with concerns about discharge coordination. These accounts contrast with the many positive descriptions of attentive care, but they point to areas families may wish to ask about directly—particularly staffing coverage, escalation processes for concerns, mobility support, and availability of specialized clinical equipment.
Reviews written on Mirador
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Medicare Ratings
5·/ 5
Overall
Health Inspection
Staffing
Quality Measures
Ratings from the U.S. Centers for Medicare & Medicaid Services (Care Compare). View on Medicare.gov
Location
Rocky Mountain Care - Evanston is located at 475 Yellow Creek Rd, Evanston, WY, 82930.
About Rocky Mountain Care - Evanston
Rocky Mountain Care - Evanston sits in Wyoming and gives a range of care options for seniors. People can get skilled nursing, rehabilitation, assisted living, independent living, memory care, and home care services here, and they focus on both short-term and long-term needs. Nurses and therapy staff can help with things like wound care, palliative care, and hospice needs, and there are physical, occupational, and speech therapy services too, including help for people who need to regain strength after orthopedic problems. Families can feel better knowing someone is there around the clock, and home health aides visit some people who want care at home with a doctor's order. The place works as a non-profit and aims to support each resident with what fits them, providing meals cooked by chefs who pay attention to nutrition, and a registered dietician helps plan the menus.
People living in Rocky Mountain Care - Evanston can have private suites with their own bathroom and shower, flat-screen televisions, and Wi-Fi for internet access, so they can stay connected or enjoy some shows if they want. For those needing memory care, the staff tries to reduce confusion and keep folks with Alzheimer's or other dementia safe from wandering. Assisted living staff support daily activities like bathing or getting dressed, but people who are independent can also live here. The center also arranges recreation therapy programs like community trips, off-site lunches, and other special events, and there are restorative therapy programs built around supervised exercise to help keep wellness up longer.
Social workers give support for emotional or life changes, and the nurses here work to meet what each person needs, so people can get care that fits just them. Community awards such as Best of Senior Living and Most Friendly show that Rocky Mountain Care - Evanston is recognized for care, activities, and having a welcoming place to stay. The building has a friendly reputation in the area as part of the broader senior living community, though what suits one person may not suit another, so it helps to ask questions and see if it's a good fit for the needs at hand.
People often ask...
Rocky Mountain Care - Evanston offers assisted living, memory care, and skilled nursing.
There are 6 photos of Rocky Mountain Care - Evanston on Mirador.
The full address for this community is 475 Yellow Creek Rd, Evanston, WY 82930.
No, Rocky Mountain Care - Evanston does not offer respite care.
Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.
Safety & Compliance
In Wyoming, the Department of Health's Healthcare Licensing & Surveys program licenses care facilities and publishes licensure, complaint, and life-safety findings.
License number
nh-195
Status
Open
Facility type
Nursing Home
Inspection Reports
120
Reports
29
Type A Citations
0
Type B Citations
23
Complaints
21
Years
25 Jun 2026Revisit
25 Jun 2026Revisit
Investigated and found no deficiencies; all prior deficiencies were corrected and no new noncompliance found.
08 Jun 2026Revisit
08 Jun 2026Revisit
Verified that prior deficiencies were corrected and no new noncompliance was found.
16 Apr 2026Licensure
16 Apr 2026Licensure
Found deficiencies in three areas: food safety labeling/handling in the kitchen, residents' rights to participate in care planning, and provision of individualized activities.
483.60(i)(1)(2)Food safety requirements
483.10(c)(2) and 483.10(c)(3)Right to Participate in Planning Care
483.24(c)(1)Activities
14 Apr 2026Life Safety
14 Apr 2026Life Safety
Found a deficiency in means of egress due to cracked and spalled concrete with abrupt elevation changes, creating a fall hazard and hindering wheelchair access.
NFPA 101, 2012 editionMeans of Egress - General
19 Mar 2025Complaint
19 Mar 2025Complaint
Investigated a complaint and found unsafe transfer practices that led to a fall with injury. A CNA did not follow the resident's care plan.
§483.25(d)(1)(2)Free of Accident Hazards/Supervision/Devices
12 Nov 2024Revisit
12 Nov 2024Revisit
Verified that all prior deficiencies were corrected and compliance was restored.
24 Oct 2024Revisit
24 Oct 2024Revisit
Confirmed compliance after a follow-up revisit. All previous deficiencies were corrected and no new noncompliance was found.
18 Sept 2024Complaint
18 Sept 2024Complaint
Found that a staff member verbally abused a resident, violating the resident's right to be free from abuse.
42 CFR 483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
22 Aug 2024Licensure
22 Aug 2024Licensure
Investigated deficiencies found in transfer/discharge notice requirements, PASARR Level II screening, and binding arbitration language for some residents.
42 CFR 483.15(c)(3)-(6)(8)Notice Requirements Before Transfer/Discharge
42 CFR 483.20(k)PASARR Screening for MD & ID
42 CFR 483.70(m)Binding Arbitration Agreements
20 Aug 2024Life Safety
20 Aug 2024Life Safety
Found deficiencies in exterior walkways with nonlevel egress and in the maintenance/testing of main and feeder electrical circuit breakers.
NFPA 101, 2012 edition; 7.7, 7.1.7; 19.2.1; 7.1.6.2Discharge from Exits
NFPA 99, Ch.10 Sec. 4.4.1.2; NFPA 110; NFPA 111; NFPA 70Electrical Systems – Main and Feeder Breakers Maintenance
28 Jul 2023Revisit
28 Jul 2023Revisit
Verified that all previously cited deficiencies were corrected and no new noncompliance was found.
06 Jul 2023Life Safety
06 Jul 2023Life Safety
Concluded compliance with emergency preparedness and life safety code requirements after review.
29 Jun 2023Licensure
29 Jun 2023Licensure
Observed that nurse staffing postings did not include the resident census or the actual hours worked per shift. Postings from 6/1/23–6/26/23 showed missing census and inaccurate staff counts.
§483.35(g)Nurse staffing information posting
29 Jun 2023Licensure
29 Jun 2023Licensure
Observed no deficiencies and determined compliance with state requirements.
02 Aug 2022Revisit
02 Aug 2022Revisit
Verified that deficiencies from a prior survey were corrected and compliance was restored.
14 Jul 2022Revisit
14 Jul 2022Revisit
Verified that all prior deficiencies were corrected and no new noncompliance was found.
19 May 2022Licensure
19 May 2022Licensure
Identified deficiencies in menu adherence for textured diets and in sanitary practices for food storage equipment. Serving sizes and diet accommodations were not consistently followed, and ice machine and cooler areas were not kept clean.
§483.60(c)Menus and nutritional adequacy
§483.60(i)(1)-(2)Food safety requirements
19 May 2022Licensure
19 May 2022Licensure
Concluded that the facility was in compliance with State requirements.
17 May 2022Life Safety
17 May 2022Life Safety
Found several life-safety and emergency preparedness deficiencies, including missing federal/state emergency contact information and problems with egress, cooking facilities, fire alarm testing, sprinkler maintenance, and gas utilities.
CFR 483.73(c)(2)Emergency Preparedness - Emergency Officials Contact Information
NFPA 101, 2012 Edition, 18.2; 19.2Means of Egress - Other
Found multiple deficiencies related to medication administration, communication/therapy services, bed-rail safety, and food handling.
42 CFR §483.25(n)(3)Self-administration of medications
—Therapy/communication services not provided
—Bed-rail safety and documentation
—Continued deficiencies related to environment and care planning
—Restraint/escort device policy and practice
13 May 2021Licensure
13 May 2021Licensure
Determined the facility was in compliance with state requirements after a licensure survey.
09 Feb 2021Revisit
09 Feb 2021Revisit
Verified no deficiencies found.
03 Feb 2021Complaint
03 Feb 2021Complaint
Investigated a complaint and a focused COVID-19 infection control survey; no deficiencies were identified.
11 Dec 2020Licensure
11 Dec 2020Licensure
Found deficiencies in infection control following a COVID-19 focused evaluation, including improper cleaning of equipment and missing written infection prevention procedures.
§483.80(a)Infection Control
22 Apr 2020Licensure
22 Apr 2020Licensure
Investigated a COVID-19 focused infection-control survey and found no deficiencies.
23 Aug 2019Revisit
23 Aug 2019Revisit
Confirmed all prior deficiencies were corrected and no new violations were found.
15 Jul 2019Revisit
15 Jul 2019Revisit
Verified that previous life safety deficiencies were corrected and compliance was restored.
15 Jul 2019Revisit
15 Jul 2019Revisit
Verified previous life safety deficiencies were corrected and compliance was restored.
06 Jun 2019Complaint
06 Jun 2019Complaint
Identified deficiencies in preventing resident-to-resident abuse, delivering quality care, managing pain, and maintaining sanitary food handling.
CFR 483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
CFR 483.25Quality of Care
CFR 483.25(k)Pain Management
CFR 483.60(i)(1)(2)Food Safety
06 Jun 2019Licensure
06 Jun 2019Licensure
Determined compliance with state requirements. Found no deficiencies.
05 Jun 2019Life Safety
05 Jun 2019Life Safety
Identified deficiencies in means of egress and sprinkler system installation. This indicated noncompliance with Life Safety Code and NFPA standards.
NFPA 101, 2012 ed., 19.3.5.1; 9.7.1.1(1); NFPA 13, 2010 ed.Means of Egress - General
Found failure to protect potable water due to aerators on sinks across the building. Aerators were removed and replaced with nominal flow devices.
WDH Chapter 3 Section 5 (b)(iv)(E)Potable water protection
11 Jun 2018Revisit
11 Jun 2018Revisit
Found no deficiencies. All previous deficiencies were corrected.
08 Jun 2018Revisit
08 Jun 2018Revisit
Concluded no deficiencies were found. All previous issues were corrected.
08 Jun 2018Revisit
08 Jun 2018Revisit
Verified that all previously cited deficiencies were corrected and no new noncompliance was found.
12 Apr 2018Licensure
12 Apr 2018Licensure
Multiple deficiencies were identified across resident rights, accommodations, survey access, transfer notices, assessments, medication management, infection control, and antibiotic stewardship.
Identified violations related to water temperature control and the administration of a CBD oil supplement without proper authorization.
Ch 11 Sec 6 (a)(iv)Water Temperature - Physical Environment
Ch 11 Sec 9 (f)(i)Administration of Drugs
09 Apr 2018Life Safety
09 Apr 2018Life Safety
Investigated deficiencies found in cooking facilities, electrical safety near a sink, fire alarm system testing, and generator electrolyte testing. Several staff training and maintenance issues were identified.
NFPA 96 (Ventilation Control And Fire Protection of Commercial Cooking Operations) – 2011 editionCooking Facilities
NFPA 101 Life Safety Code 19.3.2.5, 19.3.2.5.1; 9.2.3; 9.1.2Utilities - Gas and Electric
NFPA 101 Life Safety Code 19.3.4.3.1; 9.6; 9.6.1.5; 9.3.2.5.1Fire Alarm System - Testing and Maintenance
NFPA 110 (2010 edition) – Section 8.3.7.1; NFPA 99; NFPA 110Electrical Systems - Maintenance and Testing
26 May 2017Revisit
26 May 2017Revisit
Determined that deficiencies identified in the March 9, 2017 surveys were corrected and compliance was restored.
26 May 2017Revisit
26 May 2017Revisit
Concluded compliance was restored after follow-up surveys.
23 May 2017Revisit
23 May 2017Revisit
Determined the operation was returned to compliance after prior deficiencies from a revisit survey, with compliance restored on the specified dates.
23 May 2017Revisit
23 May 2017Revisit
Investigated and concluded that compliance was restored after revisit surveys.
09 Mar 2017Licensure
09 Mar 2017Licensure
Investigated hot water temperatures in bathroom sinks and found several exceeded 110°F; temperatures were adjusted to meet the limit and ongoing monitoring implemented.
Investigated reported deficiencies; all cited deficiencies were corrected and follow-up completed.
483.10(n)
483.13(c)(1)(ii)-(iii), (c)(2)-(4)
483.15(c)(6)
483.15(h)(2)
483.25
483.25(d)
483.35(i)
483.60(b), (d), (e)
483.70(h)
20 Apr 2016Revisit
20 Apr 2016Revisit
Identified deficiencies in life safety code compliance related to NFPA 101; a follow-up revisit occurred on 4/20/2016.
LSC; NFPA 101Life Safety Code deficiency
LSC; NFPA 101Life Safety Code deficiency
LSC; NFPA 101Life Safety Code deficiency
25 Feb 2016Complaint
25 Feb 2016Complaint
Investigated a complaint and found multiple deficiencies involving resident safety, care, and the facility environment.
Type A—Mistreatment/Neglect/Abuse - Staff
Type A—Quality of care or care planning
Type A—Food service/sanitation and equipment maintenance
Type A—Safety and sanitation – environmental conditions
Type A—Sanitation and facility environment
25 Feb 2016Licensure
25 Feb 2016Licensure
Concluded the facility was in compliance with state requirements after the survey.
23 Feb 2016Life Safety
23 Feb 2016Life Safety
Identified safety deficiencies involving exit signage illumination, emergency lighting, and proper protection of oxygen storage and related areas.
Type ANFPA 101 Life Safety Code StandardExit signage illumination
Type ANFPA 101 Life Safety Code StandardExit signage illumination (photoluminescent exit sign)
Type ANFPA 101 Life Safety Code Standard; NFPA 99 Health Care FacilitiesMedical gas storage protection
20 Mar 2015Complaint
20 Mar 2015Complaint
Investigated a complaint and found no deficiencies.
16 Mar 2015Revisit
16 Mar 2015Revisit
Investigated follow-up actions and found corrections completed for previously identified deficiencies.
19 Feb 2015Revisit
19 Feb 2015Revisit
Verified corrections completed for life-safety deficiencies cited previously.
NFPA 101 Life Safety CodeLife Safety Code deficiency
NFPA 101 Life Safety CodeLife Safety Code deficiency
NFPA 101 Life Safety CodeLife Safety Code deficiency
12 Jan 2015Life Safety
12 Jan 2015Life Safety
Investigated a complaint/incident and found multiple life-safety deficiencies, including improper smoking controls, inadequate handling of ashtrays, and sprinkler system and fire-drill documentation issues.
NFPA 101 Life Safety Code Standard, NFPA 101 Life Safety Code Section 19.7.4Smoking regulations
NFPA 101 Life Safety Code Standard, NFPA 101 Life Safety Code Section 19.7.4Smoking policy and ashtray disposal
NFPA 101 Life Safety Code Standard, NFPA 101 Life Safety Code Section 19.7.4Sprinkler system maintenance
NFPA 101 Life Safety Code Standard, NFPA 101 Life Safety Code Section 19.7.4Fire drill records and practice
12 Jan 2015Life Safety
12 Jan 2015Life Safety
Found that emergency eyewash stations lacked tempered water due to noncompliant temperature-actuated mixing valves.
ANSI Z358.1; 2006 IPC Section 411; ASSE 1071Tempered water for emergency eyewash stations (temperature-actuated mixing valve required)
08 Jan 2015Licensure
08 Jan 2015Licensure
Investigated findings showed multiple deficiencies related to updating resident representatives' contact information, fall risk management, and adherence to care plans and physician orders.
Type A—Record/update contact information for resident's representative
Type A—Falls risk assessment and care planning
Type A—Care plans and physician orders—transfers
Type A—Staff training on care plans
Type A—Documentation and follow-up on care plans
08 Jan 2015Licensure
08 Jan 2015Licensure
Concluded that the facility was in compliance with state requirements after a multi-day survey.
17 Oct 2014Revisit
17 Oct 2014Revisit
Verified corrections completed for deficiencies cited earlier; follow-up confirmed compliance.
Ch 11 Sec 11 (a)(b)Wyoming Ch 11 Sec 11 (a)(b)
20 Aug 2014Complaint
20 Aug 2014Complaint
Investigated a complaint and found no deficiencies identified.
21 Jan 2014Revisit
21 Jan 2014Revisit
Completed corrections for previously identified deficiencies.
23 Dec 2013Revisit
23 Dec 2013Revisit
Identified several Life Safety Code deficiencies and noted corrections completed.
NFPA 101 Life Safety CodeLife Safety Code deficiency
NFPA 101 Life Safety CodeLife Safety Code deficiency
NFPA 101 Life Safety CodeLife Safety Code deficiency
NFPA 101 Life Safety CodeLife Safety Code deficiency
NFPA 101 Life Safety CodeLife Safety Code deficiency
07 Nov 2013Complaint
07 Nov 2013Complaint
An investigation found deficiencies in resident care and daily-living support, with multiple observed concerns related to hygiene and proper care documentation.
Type A—Continued from page 3 – Inadequate care for activities of daily living and related documentation
07 Nov 2013Licensure
07 Nov 2013Licensure
Investigated deficiencies in dietetic services due to unverified qualification of the dietary manager and lack of documentation for course enrollment completion.
—Dietetic services not provided by a qualified supervisor
06 Nov 2013Life Safety
06 Nov 2013Life Safety
Identified life-safety deficiencies including failure to separate hazardous areas from use areas in one smoke compartment and a trip hazard from missing floor tiles near an exterior door.
NFPA 101 Life Safety Code StandardLIFE SAFETY CODE STANDARD
07 Mar 2013Complaint
07 Mar 2013Complaint
Investigated a complaint; no deficiencies were identified.
29 Nov 2012Revisit
29 Nov 2012Revisit
Investigated an allegation and cited multiple life-safety code deficiencies; corrections completed for several items.
NFPA 101 Life Safety CodeK0029
NFPA 101 Life Safety CodeK0046
NFPA 101 Life Safety CodeK0050
NFPA 101 Life Safety CodeK0052
NFPA 101 Life Safety CodeK0062
NFPA 101 Life Safety CodeK0076
NFPA 101 Life Safety CodeK0141
16 Nov 2012Revisit
16 Nov 2012Revisit
Investigated a complaint and found deficiencies; corrective actions were completed on follow-up.
25 Sept 2012Life Safety
25 Sept 2012Life Safety
Investigated deficiencies related to life-safety equipment, signage, and maintenance; several items were cited as failing to meet required standards.
NFPA 101 Life Safety Code Standard; NFPA 101, 2000 Edition; 19.3.5.1; 9.7.1.1; NFPA 13, 1999 EditionContinued From page 3 – remote stop station / lifesafety devices
NFPA 90A; NFPA 101 Life Safety Code StandardContinued From page 4 – automatic shutdown devices tested annually
NFPA Life Safety Code StandardContinued From page 5 – signage inspection
NFPA 101 Life Safety Code StandardContinued From page 7 – No Smoking signage
NFPA 101 Life Safety Code StandardContinued From page 8 – maintenance of electrical equipment
20 Sept 2012Licensure
20 Sept 2012Licensure
Identified deficiencies in organization and administration with incomplete personnel medical assessments and TB questionnaires.
Chapter 11, Section 5 (Organization and Administration)Licensing regulations for nursing homes – Organization and Administration
20 Sept 2012Licensure
20 Sept 2012Licensure
The inspection found that residents' psychosocial needs were not met for at least one resident.
—Psychosocial needs
14 Jul 2011Licensure
14 Jul 2011Licensure
Investigated and found deficiencies in care planning, with the failure to provide individualized interventions for two residents and an inadequate toileting plan.
—Care planning deficiencies
14 Jul 2011Licensure
14 Jul 2011Licensure
Found no deficiencies. Determined compliance with state requirements.
13 Jul 2011Life Safety
13 Jul 2011Life Safety
Identified several life-safety and electrical-code deficiencies, including damaged smoke-barrier doors, inadequate working space for electrical equipment, and obstructed access to electrical panels.
NFPA 101 Life Safety Code, 2000 editionDoors and smoke barriers; corridor openings
NFPA 101 Life Safety Code StandardDoor construction and smoke-resisting requirements; working space
NFPA 70, National Electrical CodeWorking space and clearance around electrical panels
01 Dec 2010Revisit
01 Dec 2010Revisit
Investigation identified deficiencies requiring correction and most corrections were completed.
03 Nov 2010Revisit
03 Nov 2010Revisit
Verified corrections completed for two fire-safety deficiencies cited during a prior survey.
NFPA 101 - Life Safety CodeLife Safety Code deficiency
NFPA 101 - Life Safety CodeLife Safety Code deficiency
21 Sept 2010Life Safety
21 Sept 2010Life Safety
Identified life-safety deficiencies including egress doors not meeting self-closing requirements and inadequate fire separation for combustibles.
NFPA 101 Life Safety Code StandardEgress and storage of combustibles
NFPA 101 Life Safety Code StandardSecure unit doorway head clearance
15 Sept 2010Licensure
15 Sept 2010Licensure
The entity was found to have multiple deficiencies related to resident assessments, care planning, and investigation of incidents. These findings show noncompliance with care standards.
15 Sept 2010Licensure
15 Sept 2010Licensure
Determined the operation was in compliance with state requirements.
07 Oct 2009Revisit
07 Oct 2009Revisit
Investigated a complaint; corrections were completed for the identified deficiencies during the follow-up visit.
07 Oct 2009Complaint
07 Oct 2009Complaint
Found no deficiencies.
28 Aug 2009Revisit
28 Aug 2009Revisit
Concluded substantial compliance after follow-up; previously cited life-safety deficiencies were corrected.
NFPA 101Life Safety Code deficiency
LSC K0012Deficiency K0012 – Life Safety Code
LSC K0029Deficiency K0029 – Life Safety Code
28 Aug 2009Revisit
28 Aug 2009Revisit
Investigated the follow-up visit and found no deficiencies.
28 Jul 2009Life Safety
28 Jul 2009Life Safety
Investigated a smoking-safety deficiency and found outdoor smoking areas lacked metal containers with self-closing covers for ashtrays, with staff unaware of the requirement.
NFPA 101, 19.7.4(3)-(4)Smoking regulations
09 Jul 2009Licensure
09 Jul 2009Licensure
Investigated a complaint and found multiple deficiencies in resident care, including care planning, nutrition, and medication oversight.
—COMPREHENSIVE CARE PLANS
—NUTRITION CARE PROCESS
—PHARMACEUTICAL REGIMEN REVIEW
—CARE PLANS FOR RESIDENTS
09 Jul 2009Licensure
09 Jul 2009Licensure
Confirmed compliance with state requirements after a survey.
07 Jul 2009Life Safety
07 Jul 2009Life Safety
Inspectors identified deficiencies related to electrical safety and plumbing backflow controls, including unsealed penetrations in the electrical room and failure to obtain plan approval for certain construction; backflow preventers also needed proper testing and scheduling.
NFPA 70 / NFPA 101 Life Safety CodeElectrical wiring and equipment
NFPA 101 Life Safety CodeBackflow prevention testing
NFPA 101 Life Safety CodeConstruction approvals / plan approval
24 Jul 2007Revisit
24 Jul 2007Revisit
Investigated a complaint and identified deficiencies in several regulatory areas; corrections were completed.
42 CFR 483.10(b)(11)
42 CFR 483.15(a)
42 CFR 483.20(a)-(i)
42 CFR 483.25(c)
42 CFR 483.25(d)
42 CFR 483.25(h)(2)
42 CFR 483.25(i)
42 CFR 483.20(k)(3)(i)
42 CFR 483.35(i)(2)
01 Jul 2007Revisit
01 Jul 2007Revisit
Verified corrections to deficiencies from the prior survey; follow-up confirmed completion of corrective actions.
17 May 2007Licensure
17 May 2007Licensure
Found a deficiency for lack of required tuberculosis testing for an employee.
State Rules and RegulationsTuberculin testing requirement for employees
17 May 2007Licensure
17 May 2007Licensure
Inspectors identified multiple deficiencies related to resident care practices, medication management, and documentation during the visit several months prior, indicating areas needing corrective action.
—Observation
—Continued From page 2 – Deficiencies related to care planning/meal service
—Continued From page 5 – Documentation/Signatures
—Unnecessary drugs
—Supervision and safety for daily living
15 May 2007Life Safety
15 May 2007Life Safety
Observed life-safety deficiencies related to smoke barriers, door hardware, penetrations, and emergency lighting during a recent inspection.
NFPA 101 Life Safety CodeDoors not latching
NFPA 101 Life Safety CodeUnsealed penetrations / conduit penetrations
NFPA 101 Life Safety Code (7.9, 19.2.9.1)Emergency lighting and smoke barrier integrity
NFPA 101 Life Safety CodeWater piping / valve condition assessment
28 Mar 2007Complaint
28 Mar 2007Complaint
Investigated a complaint and found no deficiencies identified.
01 Nov 2006Complaint
01 Nov 2006Complaint
Investigated a complaint and found no deficiencies.
09 Aug 2006Revisit
09 Aug 2006Revisit
Identified deficiencies related to resident protections and to inadequate resident assessments. Observed failures to implement policies prohibiting mistreatment and to complete comprehensive assessments for some residents.
483.13(c)Staff Treatment of Residents
483.20(k)Comprehensive Assessments
13 Jul 2006Revisit
13 Jul 2006Revisit
Investigated a prior complaint and found corrections completed for life-safety code deficiencies after follow-up.
—Life Safety Code deficiency (NFPA 101)
—Life Safety Code deficiency (NFPA 101)
—Life Safety Code deficiency (NFPA 101)
13 Jul 2006Revisit
13 Jul 2006Revisit
Investigated the matter and found no deficiencies.
16 May 2006Revisit
16 May 2006Revisit
Identified deficiencies in life-safety systems relating to remote signaling and sprinkler/alarm maintenance.
19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5NFPA 101 Life Safety Code Standard
19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5NFPA 101 Life Safety Code Standard
16 May 2006Revisit
16 May 2006Revisit
Multiple life-safety deficiencies were found in doors, emergency lighting, fire alarm testing, and sprinkler system installation.
NFPA 101 Life Safety Code StandardDoor protection/closure in corridor
NFPA 101 Life Safety Code StandardEmergency lighting
NFPA 101 Life Safety Code StandardFire alarm system maintenance/testing
NFPA 101 Life Safety Code StandardSprinkler system installation/coverage
21 Mar 2006Life Safety
21 Mar 2006Life Safety
Identified several NFPA 101 life-safety deficiencies related to door hardware, egress, and fire protection equipment during an inspection, requiring corrective actions.
NFPA 101 LIFE SAFETY CODE STANDARDCorridor/door hardware and latch operations
NFPA 101 LIFE SAFETY CODE STANDARDDoor hardware and corrective actions
NFPA 101 LIFE SAFETY CODE STANDARDContinued observations on doors (resident rooms)
NFPA 101 LIFE SAFETY CODE STANDARDFire protection equipment maintenance
NFPA 101 LIFE SAFETY CODE STANDARDElectrical/surge protection measures
NFPA 101 LIFE SAFETY CODE STANDARDGeneral electrical/wiring safety and maintenance
16 Mar 2006Revisit
16 Mar 2006Revisit
Verified corrections were completed for deficiencies previously reported.
483.13(c)
483.20, 483.20(b)
483.20(k)(3)(ii)
483.25(l)(1)
483.25(m)(1)
16 Mar 2006Licensure
16 Mar 2006Licensure
The evaluation found deficiencies related to patient privacy/confidentiality and failure to notify residents about changes to their rights and regulatory information.
Type A483.10(e); 483.75(d)(4)Privacy and Confidentiality
Type A483.10(b)(11)Notification of Changes
16 Mar 2006Life Safety
16 Mar 2006Life Safety
Investigated life-safety deficiencies related to fire alarm and sprinkler systems and related notification practices; identified multiple violations.
NFPA 101 Life Safety Code StandardLife Safety Code Standard – Fire Alarm System
NFPA 101 Life Safety Code StandardLife Safety Code Standard – Sprinkler System (General)
NFPA 101 Life Safety Code StandardLife Safety Code Standard – Automatic Sprinkler System Maintenance
NFPA 101 Life Safety Code StandardLife Safety Code Standard – Sprinkler System Downtime
NFPA 101 Life Safety Code StandardLife Safety Code Standard – Fire Watch/Notification
16 Mar 2006Licensure
16 Mar 2006Licensure
Observed a license was not posted in a public area, indicating noncompliance with licensure posting requirements.
Wyoming Rules for Licensure of Nursing Care Facilities, Section 5(h) Posting of LicensePosting of License
13 Mar 2006Licensure
13 Mar 2006Licensure
Identified deficiencies in governance and administration, including lack of an on-site administrator with a current Wyoming license and insufficient governing body oversight.
14 Nov 2005Revisit
14 Nov 2005Revisit
Cited deficiencies in several regulatory areas and noted corrections were completed by the revisit date.
483.10(g)(1)
483.15(f)(1)
483.15(h)(2)
483.20(a)
483.25(d)
483.35(h)(2)
483.75(i)(1)
04 Oct 2005Revisit
04 Oct 2005Revisit
Investigated deficiencies identified in a prior survey and found corrections completed.
22 Sept 2005Licensure
22 Sept 2005Licensure
Identified multiple deficiencies in regulatory compliance, including failure to post survey results, inadequate activities, incomplete resident assessments, and unsafe physical conditions.
483.10(g)(1)Examination of survey results
483.15(f)(1)Activities
483.20(h)(2)Comprehensive assessments
483.70Physical environment
22 Sept 2005Revisit
22 Sept 2005Revisit
Identified deficiencies in medication administration, care planning, and medical recordkeeping. Multiple instances of incomplete documentation and updated plans were observed during the review.
Type A—Professional standards of quality in provided services
Type A—Care planning must be updated to reflect residents' needs
Type A483.25(h)(1)Accidents and incident documentation
Type A—Clinical records must be complete, accurate, and accessible
22 Sept 2005Revisit
22 Sept 2005Revisit
Found deficiencies in medication administration; several residents had medications not documented as given or not administered as ordered.
—Administration of Drugs
22 Sept 2005Revisit
22 Sept 2005Revisit
Investigated and found medication administration documentation deficiencies; several doses were not documented as given for residents.
—Medication administration not documented
15 Aug 2005Complaint
15 Aug 2005Complaint
Investigated deficiencies in the handling of resident assessments and care planning. The facility failed to ensure timely and accurate assessments were conducted and reflected in resident status.
—Resident Assessment/Comprehensive Assessment
—Accurate Assessment of Resident Status
15 Aug 2005Licensure
15 Aug 2005Licensure
Determined there were missing documentation for medications for several residents and multiple medications were not documented as administered.
09 Aug 2005Life Safety
09 Aug 2005Life Safety
Identified multiple life-safety deficiencies, including gaps in smoke barrier/door integrity, sprinkler and extinguishing system issues, and electrical wiring concerns.
Type ANFPA 101 Life Safety Code 19.3.6.3.6; 19.3.7.3.3; 19.3.7.3.6Smoke barriers and doors
Type ANFPA 101 Life Safety Code 19.3.2.1; 19.3.5.4Smoke barrier/door integrity (continued)
Type ANFPA 13; NFPA 25; NFPA 101 9.3.5.4Sprinkler system and extinguishers
Type ANFPA 99; NFPA 101Emergency/Life-safety electrical architecture
Type ANFPA 13; NFPA 25; NFPA 99Automatic sprinkler system maintenance
Type ANFPA 10; NFPA 70Portable extinguishers and electrical standards
Type ANFPA 99; NFPA 10; NFPA 70Electrical/system reconfiguration for life safety
Type ANFPA 101; NFPA 70; NFPA 99Electrical wiring and equipment standards
26 May 2005Revisit
26 May 2005Revisit
Identified deficiencies related to resident rights and care requirements; corrections completed.
483.20(b)Resident rights
483.20(g)-(h)483.20(g)-(h)
483.20(k)483.20(k)
483.20(k)(3)(i)483.20(k)(3)(i)
06 May 2005Revisit
06 May 2005Revisit
Identified deficiencies in resident assessments and care planning, including missing or incomplete assessments and failure to certify assessments properly.
483.20(b)RESIDENT ASSESSMENT
483.20(g)-(h)RESIDENT ASSESSMENT
483.20(k)(3)RESIDENT ASSESSMENT
02 Mar 2005Complaint
02 Mar 2005Complaint
Identified multiple deficiencies in resident care planning, privacy, and staff accountability.
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