Big Horn Rehabilitation and Care Center

    1851 Big Horn Ave, Sheridan, WY 82801
    • Assisted Living
    • Memory Care
    • Skilled Nursing

    Caring, respectful, family-like rehab experience

    I'm very grateful for the caring, compassionate staff at Big Horn - residents are treated with respect and the team creates a warm, family-like atmosphere. My loved one had successful therapy and a supportive rehab stay; communication is clear, visits are always welcome, and community events (like the parade) bring joy. New owners are making visible improvements and remodeling is underway; overall a very positive, care-focused place I highly recommend.

    Loved one of resident
    Jul 2026

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    Reviews

    3.62·(26)

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      3.7
    • Staff

      3.6
    • Meals

      1.0
    • Amenities

      1.5
    • Value

      3.5

    Pros

    • Compassionate, respectful caregiving staff
    • Skilled physical and occupational therapists
    • Supportive, family-like atmosphere
    • Open visitation and strong family communication
    • Staff longevity and employee commitment
    • Ongoing remodeling and facility improvements
    • Opportunities for staff advancement
    • Successful long-term care placements

    Cons

    • Cleanliness and odor concerns in some areas
    • Incontinence-care delays and inconsistent personal-care timing
    • Delays in responding to resident requests
    • Persistent understaffing and high turnover
    • Poor and inconsistent food quality and nutritional management
    • Limited rehabilitation availability and reduced weekend services
    • Aging building and deferred maintenance
    • Weak complaint-resolution and management follow-through
    • Questionable online review authenticity
    • Billing and pricing transparency concerns

    Summary of reviews

    Reviews indicate a facility with noticeable strengths in the interpersonal and therapeutic aspects of care, alongside recurring operational shortcomings. Many families praise the caregiving staff as compassionate, patient, and respectful; reviewers frequently cite warm, family-like relationships between staff and residents, open visiting policies, and good two-way communication with families. Physical and occupational therapists receive particular positive mention for skill and encouragement, and several accounts describe meaningful functional improvements during stays. The facility also appears to be undergoing some positive changes under new ownership, including remodeling efforts and greater attention to staff development and advancement.

    At the same time, a number of consistent concerns emerge around basic operations. Multiple reviewers describe cleanliness and odor concerns in common areas and resident rooms, and note delays in personal-care tasks, including assistance after incontinence events. Families also reported slow responses to call buttons and uneven attention to routine needs, which reviewers link to staffing shortfalls and elevated staff turnover. These operational gaps are paired with comments about limited therapy schedules—notably reduced or no weekend therapy—and variable rehabilitation intensity, which can affect short-term recovery expectations.

    Dining and nutrition are another frequent source of dissatisfaction. Several families attributed weight loss and illness to inconsistent or poor-quality meals, describing food that some found unpalatable or unsuitable for their loved ones. Reviewers raised questions about the facility’s nutritional management and meal-service consistency; there were also comments about billing and perceived overcharging in at least one account.

    Facility condition and management practices draw mixed commentary. While remodeling and other improvements have been noted, the building is described as older with areas needing maintenance. Some reviewers expressed frustration that complaints were not effectively resolved by management, and a pattern of administrative instability and perceived lack of investment in staff and the physical plant was reported. There are also isolated allegations suggesting incentivized positive online reviews, which some readers may view as reducing the reliability of the review profile.

    Overall, prospective residents and families should weigh the clear strengths in staff compassion, therapeutic skill, and a welcoming culture against operational weaknesses in cleanliness, timely personal care, meal quality, and management responsiveness. A recommended next step for families considering this facility is an in-person visit that includes a tour of several resident areas, discussion about staffing ratios and weekend therapy availability, a review of recent renovation plans, and direct questions about how the facility tracks and responds to family complaints and nutrition concerns.

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    Medicare Ratings

    1·/ 5
    • Overall

    • Health Inspection

    • Staffing

    • Quality Measures

    Ratings from the U.S. Centers for Medicare & Medicaid Services (Care Compare). View on Medicare.gov

    Location

    Map showing location of Big Horn Rehabilitation and Care Center

    Big Horn Rehabilitation and Care Center is located at 1851 Big Horn Ave, Sheridan, WY, 82801.

    About Big Horn Rehabilitation and Care Center

    Sheridan Manor sits at 1851 Big Horn Ave in Sheridan, Wyoming, and serves as a skilled nursing and long-term care facility that covers a lot of needs for older adults, with a setting that feels both comfortable and home-like, offering residents a chance to age in place because the community gives options for independent living, assisted living, memory care, and skilled nursing all under one roof, which means residents who start out living on their own can later switch easily to assisted living or even full-time nursing care without leaving familiar faces behind, and you'll find care that covers everything from help with dressing and bathing, medication management, transfers, and meals to more advanced services like short-term rehabilitation, wound care, and comprehensive nursing support with round-the-clock supervision for those who need it, and there are memory care programs designed in secure areas that help residents with Alzheimer's or dementia stay safe, comfortable, and engaged, with activities and therapies made to ease confusion and prevent wandering, plus access to social services, including family counseling and dementia care counseling, so no one feels left out or alone, and the activity programs aim to keep everyone as active as possible no matter their abilities, with things like wellness programs, movie nights in the community's theater, outings along walking paths and garden areas, spa or sauna visits, trips to the library, or fitness room sessions, and there's help with things like laundry, housekeeping, transportation, and move-in coordination, so daily life gets a bit easier, and independent living options let active seniors enjoy maintenance-free living with handy features like private bathrooms, kitchenettes, air conditioning, Wi-Fi, cable television, and furnished rooms if needed, alongside resort-style perks and all-day dining, with meals especially made to handle special diets by professional chefs, and there's an emergency alert system and 24-hour call system built in, so people know help is always close by, and what's more, Sheridan Manor has been recognized for its friendly staff, great meals, and strong social activity programs, so it seems like they really care about making everyone feel valued and supported, and for those who need a short break, respite care is also available, giving caregivers a way to rest while knowing their loved one's getting the support they need.

    People often ask...

    Big Horn Rehabilitation and Care Center offers assisted living, memory care, and skilled nursing.

    There are 1 photos of Big Horn Rehabilitation and Care Center on Mirador.

    The full address for this community is 1851 Big Horn Ave, Sheridan, WY 82801.

    No, Big Horn Rehabilitation and Care Center 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 numbernh-213
    Facility typeNursing Home

    Inspection Reports

    154

    Reports

    7

    Type A Citations

    0

    Type B Citations

    76

    Complaints

    21

    Years

    03 Mar 2025Revisit
    Verified previous deficiencies were corrected and no new noncompliance was found.
    15 Jan 2025Complaint
    Found that three resident-to-resident abuse allegations were not reported within required timeframes and reporting procedures were not properly followed.
    • CFR 483.12Reporting of Alleged Violations
    13 Jan 2025Revisit
    Determined that all prior deficiencies were corrected and no new violations were found. Revisit confirmed compliance.
    13 Jan 2025Revisit
    Verified that all previously cited deficiencies were corrected and no new noncompliance was found.
    07 Nov 2024Revisit
    Investigated staffing issues found insufficient nursing coverage on a courtyard unit. This led to medication administration gaps on 10/10/24.
    • 42 CFR 483.35(a)(1)(2)Sufficient Staff
    07 Nov 2024Complaint
    Found deficiencies in nutrition management, staffing, and record-keeping after investigation.
    • CFR 483.25(g)(1)-(3)Nutrition/Hydration Status Maintenance
    • CFR 483.35(a)(1)-(2)Sufficient Staffing
    • CFR 483.20(f)(5), 483.70(h)(1)-(5)Resident Records - Identifiable Information
    09 Oct 2024Revisit
    Verified compliance with all life safety requirements; no deficiencies were found.
    13 Sept 2024Complaint
    Investigated a complaint and survey identified deficiencies in mail privacy, advance directives, PASARR processing, daily living assistance, staffing, and medication labeling.
    • 483.10(g)(6)-(9)Right to Forms of Communication w/ Privacy
    • 483.10(c)(6); 483.10(g)(12)Advance Directives
    • 483.20(k)(1)-(3)Preadmission Screening for Mental Illness/Intellectual Disability (PASARR)
    • 483.24(a)(2)ADL Care Provided for Dependent Residents
    • 483.35(a)(1)-(2)Sufficient Nursing Staff
    • 483.45(g)-(h)(1)-(2)Label/Store Drugs and Biologicals
    12 Sept 2024Life Safety
    Identified life-safety deficiencies including incomplete testing of the kitchen hood extinguishing system, noncompliant interior wall finishes, and missing maintenance plan for essential electrical systems.
    • 42 CFR 483.90Cooking Facilities
    • 42 CFR 483.90Interior Wall and Ceiling Finish
    • 42 CFR 483.90Electrical Systems - Other
    28 May 2024Revisit
    Verified compliance with life safety requirements; prior deficiencies were corrected and no new noncompliance was found.
    03 May 2024Revisit
    Found no deficiencies and determined continued compliance after a revisit.
    03 May 2024Revisit
    Verified that all deficiencies were corrected and no new noncompliance was found.
    04 Apr 2024Licensure
    Identified deficiencies in MDS accuracy, care planning participation, and medication storage. Found misclassification of anticoagulant/antiplatelet use in MDS, lack of resident/guardian involvement in care conferences, and expired meds in storage.
    • CFR 483.20(g)Accuracy of Assessments
    • CFR 483.21(b)(2)Care Plan Timing and Revision
    • CFR 483.45(g)(h)(1)(2)Labeling of Drugs and Biologicals / Storage of Drugs and Biologicals
    04 Apr 2024Life Safety
    Identified several life-safety deficiencies related to egress doors, hazardous areas, fire alarm testing, sprinkler maintenance, and essential electrical systems. The findings showed noncompliance with safety requirements.
    • Egress Doors
    • Hazardous Areas - Enclosure
    • Fire Alarm System - Testing and Maintenance
    • Sprinkler System - Maintenance and Testing
    • Electrical Systems - Essential Electric System
    04 Apr 2024Licensure
    Identified TB screening deficiencies for multiple staff members. No evidence of annual TB testing for several employees.
    • Wyoming Chapter 11 Section 5(b) - Organization and AdministrationOrganization and Administration
    23 Feb 2024Complaint
    Concluded that no deficiencies were identified during the complaint investigation.
    21 Dec 2023Complaint
    Investigated abuse concerns and found deficiencies in protecting residents from physical abuse, with harm occurring to a resident.
    • CFR 483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
    21 Nov 2023Revisit
    Found no deficiencies.
    08 Nov 2023Revisit
    Found no deficiencies; prior deficiencies were corrected.
    24 Oct 2023Complaint
    Found no deficiencies identified in relation to the complaint investigation.
    05 Oct 2023Complaint
    Investigated multiple deficiencies across care delivery, food safety, nurse aide registry verification, and call light accessibility, indicating gaps in timely resident care, proper kitchen practices, credential verification, and call system accessibility.
    • CFR 483.25Quality of Care
    • CFR 483.35(d)(4)-(6)Nurse Aide Registry Verification, Retraining
    • CFR 483.60(i)Food Safety Requirements
    • CFR 483.90(g)Resident Call System
    05 Oct 2023Licensure
    Concluded the provider met state requirements. No deficiencies were cited.
    03 Oct 2023Life Safety
    Identified multiple deficiencies in hazardous area protection, cooking facility ventilation, and maintenance of life-safety systems and electrical equipment.
    • 2012 NFPA 101 19.3.2.1.3Hazardous Areas - Enclosure
    • 2012 NFPA 101 19.3.2.5.1, 9.2.3; 2011 NFPA 96 11.4, 11.5Cooking Facilities
    • 2012 NFPA 101 9.6.1.3, 9.6.1.5; NFPA 70; NFPA 72Fire Alarm System - Testing and Maintenance
    • 2011 NFPA 25 13.2.5, 13.6.2.1, 13.4.4.2.4, 13.4.4.2.2.2Sprinkler System - Maintenance and Testing
    • 2012 NFPA 101 19.5.2.1, 9.2.1; 2012 NFPA 90A 5.4.8; 2010 NFPA 80 19.4.1HVAC
    • 2012 NFPA 101 19.7.6, 8.3.3.1; 2010 NFPA 80 5.2.1Maintenance, Inspection & Testing - Doors
    • NFPA 99 6.3.4.1, 6.3.3.2; NFPA 70Electrical Systems - Maintenance and Testing
    • 2012 NFPA 99 10.2.3.6; 10.2.4; CMS S&C 14-46-LSCElectrical Equipment - Power Cords and Extension Cords
    03 Aug 2023Complaint
    Found no deficiencies pertaining to the complaint investigation.
    29 Jun 2023Revisit
    Verified prior deficiencies were corrected and no new noncompliance was found.
    12 May 2023Complaint
    Investigated a complaint involving resident-to-resident aggression and found a resident was struck in the face with a belt, causing injury; identified a failure to protect residents from abuse by another resident.
    • 42 CFR 483.12(a)Freedom from Abuse, Neglect, and Exploitation
    19 Apr 2023Revisit
    Verified compliance after a follow-up survey; no deficiencies were cited.
    14 Mar 2023Revisit
    Concluded that all previously cited deficiencies were corrected and compliance restored.
    08 Feb 2023Life Safety
    Identified multiple life safety and emergency preparedness deficiencies, including missing emergency contact information, lack of reliable emergency power documentation, unsecured gas/O2 storage, improper door hardware, and unsafe electrical and heating practices.
    • 42 CFR 483.73(c)(2)Emergency Officials Contact Information
    • 42 CFR 483.73(e)(2); NFPA 101; NFPA 99; NFPA 110Hospital CAH and LTC Emergency Power
    • 2012 NFPA 101 Section 7.2.1.8.2Doors with Self-Closing Devices
    • 2012 NFPA 101 Section 19.3.2.1Hazardous Areas - Enclosure
    • NFPA 72 (2010 edition), Table 14.3.1(3)(d)Fire Alarm System - Testing and Maintenance
    • NFPA 13 (2010 edition); NFPA 101 Sections 19.3.5.1; 9.7.1.1(1)Sprinkler System - Installation
    • NFPA 101 2012 Section 19.7.8Portable Space Heaters
    • NFPA 101 2012 Section 9.1.2; NFPA 70 2011 Section 400.8Electrical Equipment - Power Cords and Extension Cords
    • NFPA 99 2012 Sections 11.3.1; 5.1.3.3.2(2); 11.3.4.1; 11.3.4.2Gas Equipment - Cylinder and Container Storage
    • NFPA 99 2012 Sections 11.5.2.3.1; 11.5.2.3.2Gas Equipment - Transfilling Cylinders
    • NFPA 101 19.5.1; 9.1.2; NFPA 99 6.4.1; NFPA 110 5.1.4Electrical Systems - Other
    08 Feb 2023Licensure
    Investigated findings showed multiple deficiencies across rights, care planning, medication management, safety, infection control, and immunizations during the survey.
    • 483.10(a)(1)(2); 483.10(b)(1)(2)Resident Rights
    • 483.10(c)(7)Self-Admin Meds-Clinically Appropriate
    • 483.20(g)Accuracy of Assessments
    • 483.21(a)(1)Baseline Care Plans
    • 483.21(b)(1)(3)Comprehensive Care Plans
    • 483.25(d)(1)(2)Accidents/ Hazards
    • 483.35(g)Posted Nurse Staffing Information
    • 483.45(c)(5)Drug Regimen Review
    • 483.45(e)(1)-(5)Free from Unnecessary Psychotropic Meds/PRN Use
    • 483.45(h)(1)-(2)Label/Store Drugs and Biologicals
    • 483.60(i)Food Procurement/Store/Prepare/Serve-Sanitary
    • 483.80(a)(1)(2)(4)(e)(f)Infection Prevention & Control
    • 483.80(d)(1)(2)Influenza and Pneumococcal Immunizations
    • 483.80(d)(3) (i)-(vii)COVID-19 Immunization
    08 Feb 2023Licensure
    Concluded no deficiencies were found and state requirements were met.
    22 Dec 2022Complaint
    Found no deficiencies identified during the complaint investigation conducted in December 2022.
    03 Nov 2022Complaint
    Found no deficiencies identified related to the complaints.
    02 Nov 2022Revisit
    Verified that previously cited deficiencies were corrected and found no new noncompliance.
    02 Sept 2022Complaint
    Found failures to protect residents from abuse in resident-to-resident incidents, an inadequate CPR response for a resident, and insufficient wound care for a pressure injury.
    • CFR 483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
    • CFR 483.24(a)(3)Cardio-Pulmonary Resuscitation (CPR)
    • CFR 483.25(b)(1)(i)(ii)Skin Integrity - Pressure ulcers
    04 May 2022Revisit
    Concluded no deficiencies; all previous deficiencies were corrected on the revisit.
    30 Mar 2022Complaint
    Investigated the complaint and found no deficiencies.
    18 Mar 2022Complaint
    Investigated a deficiency in administering COVID-19 booster vaccinations; policies to offer boosters in a timely manner were not in place for a resident who requested one.
    • 42 CFR 483.80(d)(3)COVID-19 immunizations
    18 Jan 2022Revisit
    Verified all previous deficiencies were corrected and no new noncompliance was found.
    29 Dec 2021Revisit
    Verified deficiencies were corrected and compliance restored.
    24 Nov 2021Life Safety
    Identified multiple life-safety deficiencies, including unsecured corridor doors, an incomplete smoke barrier, and improper use of power strips in patient care areas.
    • NFPA 101 19.3.6.3.5 (2)Corridor doors not self-latching with proper hardware
    • NFPA 101 19.3.7.3, 8.5.6, 8.5.5.2Smoke barrier not maintained/sealed
    • NFPA 99 10.2.3.6Power strips used in patient care areas with PCREE near medical devices
    18 Nov 2021Licensure
    Investigated deficiencies found in personal funds accounting, environment cleanliness, transfer/bed-hold notices, infection control, and pest control.
    • 42 CFR 483.10(f)(10)(iii)Accounting and Records of Personal Funds
    • 42 CFR 483.10(i)Safe, Clean, Comfortable, Homelike Environment
    • 42 CFR 483.15(c)Notice Requirements Before Transfer/Discharge
    • 42 CFR 483.15(d)Notice of Bed-Hold Policy Before/Upon Transfer
    • 42 CFR 483.80Infection Prevention & Control
    • 42 CFR 483.90(i)(4)Maintains Effective Pest Control Program
    18 Nov 2021Licensure
    Concluded compliance with state requirements following a licensure survey. No deficiencies were cited.
    06 Aug 2021Complaint
    Found no deficiencies. The complaint intake review and a COVID-19 focused infection control review identified no deficiencies.
    22 Jul 2021Revisit
    Verified no deficiencies were found on follow-up. All previously cited deficiencies were corrected.
    20 May 2021Complaint
    Investigated found failures to implement preventive interventions for pressure ulcers for two residents, with documentation gaps and delayed care planning, plus issues with oxygen tubing padding contributing to skin risk.
    • CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin IntegrityTreatment/Svcs to Prevent/Heal Pressure Ulcer
    08 Apr 2021Revisit
    Verified that all prior deficiencies were corrected and found no new noncompliance.
    16 Feb 2021Complaint
    Investigated a complaint alleging verbal abuse by a transportation staff member toward a resident and evaluated infection control practices; found abuse and improper PPE use on a unit.
    • CFR 483.12Freedom from Abuse, Neglect, and Exploitation
    • CFR 483.80Infection Control
    04 Nov 2020Revisit
    Verified that prior deficiencies were corrected and no new noncompliance was found. The site is in compliance with all regulations surveyed.
    25 Sept 2020Complaint
    Investigated a complaint about discharge planning and found a deficiency in the discharge planning process for one resident. The issue involved incomplete planning and coordination for post-discharge care, including home health services.
    • 42 CFR 483.21(c)(1)-(ix)Discharge Planning Process
    10 Apr 2020Licensure
    Determined that no deficiencies were identified during the COVID-19 focused infection control survey conducted on 4/9/20 through 4/10/20.
    13 Feb 2020Complaint
    Investigated a complaint about a burn hazard and related care concerns; identified safety and care issues, with corrective actions completed by mid-January 2020.
    • CFR 483.25(d)(1)(2)Free of Accident Hazards/Supervision/Devices
    23 Dec 2019Revisit
    Found no deficiencies. All regulations surveyed were in compliance.
    09 Dec 2019Revisit
    Concluded that all prior deficiencies were corrected and no new noncompliance was found; in compliance with Emergency Preparedness Rules.
    13 Nov 2019Revisit
    Verified no deficiencies related to emergency preparedness and confirmed compliance with all applicable rules.
    15 Oct 2019Licensure
    Found lack of a formal emergency preparedness training program; initial training and demonstrated staff knowledge of emergency procedures were not conducted.
    • CFR 483.73(d)(1)Emergency preparedness training program
    15 Oct 2019Life Safety
    Identified deficiencies in fire safety systems, emergency preparedness, and electrical safety, with corrective actions planned and implemented.
    • NFPA 101 Life Safety Code (2012) – Fire alarm and sprinkler system installationFire alarm system not installed/maintained according to code
    • NFPA 25 / NFPA 101 (life safety) – Sprinkler system maintenance and testingMaintenance/testing of sprinkler system not adequately documented or performed
    • Emergency preparedness program not developed or maintained
    • Emergency preparedness training
    • NFPA 101 (Life Safety Code) / NFPA 101 – Electrical safetyElectrical equipment – power cords and extension cords
    10 Oct 2019Licensure
    Identified multiple deficiencies across grievances, abuse reporting/investigation, care planning, pharmacy, dietary staffing, menus, and infection control.
    • §483.10(j) GrievancesGrievances
    • §483.12(c)(1)-(4)Reporting of Alleged Violations
    • §483.12(c)(2)-(4)Investigate/Prevent/Correct Alleged Violations
    • §483.21(b)(1)Develop/Implement Comprehensive Care Plan
    • §483.45(a)-(b)Pharmacy Services
    • §483.60(a)(1)-(2)Qualified Dietary Staff
    • §483.60(c)(1)-(7)Menus/Meal Preparation
    • §483.80(a)-(f)Infection Prevention & Control
    10 Oct 2019Licensure
    Concluded compliance with state requirements. No deficiencies were cited.
    07 Oct 2019Revisit
    Verified prior deficiencies were corrected and no new noncompliance was found; overall compliance with regulations.
    27 Aug 2019Complaint
    An investigation found deficiencies related to at‑risk resident behavior management and to discharge/transfer decisions, with required corrective actions identified.
    • 483.15(c)(1)(i)-(iii)Behavior management and at‑risk behaviors
    • 483.15(c)(2)Discharge planning
    • 483.15(c)(2)Discharge planning – continued
    07 Aug 2019Revisit
    Verified compliance with all regulations; previous deficiencies were corrected and no new noncompliance found.
    04 Jun 2019Complaint
    Identified deficiencies in environment and food service, including inadequate lighting, temperature control, and mismatches between tickets and posted menus.
    • Type A§483.10(i)(5)-(7)Adequate lighting and comfortable environment
    • Type A§483.60(c)(2)-(4)Dietary service - ticketing and posted menu accuracy
    10 Dec 2018Revisit
    Verified all prior deficiencies were corrected and no new noncompliance was found.
    10 Dec 2018Revisit
    Confirmed compliance with all regulations surveyed; prior deficiencies corrected and no new noncompliance found.
    22 Oct 2018Revisit
    Investigated the previous deficiencies and confirmed all were corrected. No new noncompliance was found.
    13 Sept 2018Licensure
    Investigated and cited deficiencies related to staff tuberculosis testing, reporting of communicable diseases, and resident health surveillance.
    • Tuberculin testing not conducted prior to contact by staff
    • Information to Licensing Division related to disease/condition
    • Audit and identification of others / resident surveillance
    13 Sept 2018Complaint
    Found deficiencies related to resident rights, care monitoring, and record-keeping during the inspection.
    12 Sept 2018Life Safety
    Investigated deficiencies in emergency preparedness and safety related to kitchen-dining area access and missing volunteer procedures during emergencies.
    20 Apr 2018Complaint
    Identified deficiencies in meal safety and resident nutrition, with past noncompliance noted.
    • Type AContinued From page 1
    05 Apr 2018Revisit
    Identified no deficiencies.
    08 Mar 2018Complaint
    Investigated a resident fall and related care deficiencies; found failures to perform timely neurological assessments and follow-up after the incident.
    • CFR 483.25Quality of Care
    08 Mar 2018Revisit
    Verified that all previously cited deficiencies were corrected during the follow-up.
    18 Jan 2018Complaint
    Identified several deficiencies in resident care and staffing, including delayed baths, insufficient nursing staff, and problems with posting staffing information.
    • Type ACFR 483.24(a)(2)ADL Care Provided for Dependent Residents
    • Type ACFR 483.24(a)(2)ADL Care Provided for Dependent Residents
    • Type ACFR 483.35(a)(1)(2)Sufficient Nursing Staff
    • Type ACFR 483.35(g)(1)-(4)Post Nurse Staffing Information
    05 Dec 2017Complaint
    Investigated a complaint survey conducted from 12/04/2017 to 12/05/2017 and found no deficiencies.
    16 Nov 2017Revisit
    Found no deficiencies. A follow-up survey showed all previous deficiencies corrected and compliance with the surveyed regulations.
    08 Nov 2017Revisit
    Verified that all previous deficiencies were corrected and no new noncompliance was found.
    14 Sept 2017Complaint
    The Wyoming health regulator found multiple deficiencies in the facility, including unsafe environmental conditions, impaired maintenance of the building, and problems with resident care planning and monitoring processes.
    • Safety/Environmental hazards in building
    • Ongoing monitoring and quality improvement
    • Care planning adequacy
    • Care planning adequacy and changes of condition
    • Infection control and sanitation monitoring
    • Food service monitoring and safety
    14 Sept 2017Licensure
    Found no deficiencies; the survey determined compliance with state requirements.
    13 Sept 2017Life Safety
    Identified multiple life-safety deficiencies related to maintenance and testing of fire protection systems and smoke barriers.
    • NFPA 101 Life Safety Code (2012), 9.7.5, 9.7.7, 9.7.8; NFPA 25Maintenance and testing of fire protection systems
    • NFPA 101 Life Safety Code (2012), 19.3.5.12, 7.2.1.2; NFPA 10Portable fire extinguishers not maintained/tested per standard
    • NFPA 101 Life Safety Code (2012), 19.3.7.3; 8.6.7.1(1)Smoke barriers/smoke compartment integrity
    • NFPA 101 Life Safety Code (2012), 19.3.5.12; 7.2.1.2; NFPA 10Monitoring/compliance with portable fire extinguishers
    25 Jan 2017Revisit
    Investigated the revisit; found no deficiencies.
    06 Dec 2016Revisit
    Found a life-safety deficiency due to non-functioning exhaust ventilation that did not meet required standards.
    • Chapter 3 Wyoming Rules and Regulations for Health Care FacilitiesState Miscellaneous Life Safety
    29 Nov 2016Revisit
    Investigated a complaint and identified Life Safety Code deficiencies; a follow-up confirmed corrections were completed.
    • NFPA 101Life Safety Code deficiency
    • NFPA 101Life Safety Code deficiency
    • NFPA 101Life Safety Code deficiency
    14 Nov 2016Revisit
    Investigated the revisit and found no deficiencies.
    14 Nov 2016Revisit
    Verified corrections to previously cited deficiencies were completed. Follow-up confirmed ongoing compliance.
    08 Nov 2016Life Safety
    Investigated a Life Safety Code licensure complaint; found no deficiencies.
    13 Oct 2016Complaint
    Investigated a complaint survey conducted from 2016-10-12 to 2016-10-13 and found no deficiencies.
    22 Sept 2016Complaint
    Investigated and found deficiencies related to safety hazards, sanitation, and maintenance in several areas.
    22 Sept 2016Licensure
    Inspected a nursing/board facility; identified deficiencies in hot water temperature safety and dietetic supervision. Noted actions planned to correct these issues.
    • Ch 11 Sec 6 (a)(iv) Physical EnvironmentPhysical Environment
    • Ch 11 Sec 11(a)(1) Dietetic ServicesDietetic Services
    21 Sept 2016Life Safety
    Found deficiencies related to storage space and exhaust ventilation. Observations documented insufficient closet/wardrobe space and improper exhaust ventilation in multiple areas.
    • Wyoming Department of Health Chapter 3 RulesState Miscellaneous Life Safety
    21 Sept 2016Life Safety
    Inspected deficiencies were identified in life-safety areas including exit signage, door hardware, pull stations, and electrical safety.
    • NFPA 101 Life Safety Code StandardExit signage
    • NFPA 101 Life Safety Code StandardPull stations/egress hardware height
    • NFPA 101 Life Safety Code StandardDoor locking/egress
    • NFPA 70 National Electrical CodeElectrical safety and wiring
    • NFPA 101 Life Safety Code StandardElectrical safety standards for equipment
    14 Sept 2016Revisit
    Investigated a complaint and found a deficiency related to residents' rights; corrective action completed.
    • 483.25(c)Rights of residents - Privacy/Protection from abuse, neglect, and exploitation
    14 Sept 2016Revisit
    Found no deficiencies cited during the revisit.
    29 Jul 2016Complaint
    Investigated a pressure ulcer care deficiency; there were ongoing wounds with inadequate documentation and inconsistent nursing oversight.
    • Treatment/Services to prevent/heal pressure ulcers
    22 Mar 2016Complaint
    Investigated abuse allegations; found failures to thoroughly investigate or report allegations for three residents with reported incidents.
    • Investigation and reporting of abuse/neglect
    09 Nov 2015Revisit
    Verified corrections completed for previously identified deficiencies.
    • 483.13(c)(1)(i)-(iii); 483.13(c)(2)-(4)Reg 483.13(c)(1)(i)-(iii); (c)(2)-(4)
    • 483.15(h)(2)Reg 483.15(h)(2)
    • 483.25Reg 483.25
    • 483.35(d)(1)-(2)Reg 483.35(d)(1)-(2)
    • 483.35(i)Reg 483.35(i)
    • 483.75(d)(11)Reg 483.75(d)(11)
    14 Oct 2015Revisit
    Investigated and verified corrections completed for prior deficiencies.
    20 Aug 2015Licensure
    Investigated a dietary management concern and found the dietary manager was not certified or qualified.
    • Dietary Manager Qualification
    20 Aug 2015Complaint
    Identified deficiencies in sanitation and care quality, including housekeeping, nutrition, and food service practices, with corrective actions planned.
    • 483.15(h)(2)Housekeeping & Maintenance Services
    • 483.25(d)(1)-(2)Nutritive Value/Appearance/Palatability/Temperature
    • Temperature Management during Meal Service
    19 Aug 2015Life Safety
    Identified life-safety deficiencies related to smoke barrier door closures and exit-access restrictions, with corrective actions taken to address the issues.
    • NFPA 101 Life Safety Code Standard; 2000 NFPA 101 Section 19.3.6.3.2Cross-corridor smoke barrier door not fully closed
    • NFPA 101 Life Safety Code Standard; 2000 NFPA 101 Sections 19.3.6.3 and relatedExit access and smoke barrier separation not maintained
    • NFPA 101 Life Safety Code StandardSmoke barrier doors not closing properly
    • NFPA 101 Life Safety Code Standard; 2000 NFPA 101 Sections 19.2.2.2.1, 7.2.1.4.5, 7.2.1.6.1, 7.2.1.5.1Exit access and egress documentation not maintained
    03 Aug 2015Complaint
    Investigated a complaint and found no deficiencies.
    23 Jul 2015Life Safety
    Identified deficiencies related to smoke barrier doors not fully closing and missing flame-spread labeling documentation for window coverings. Also noted plans for follow-up audits to verify compliance.
    • NFPA 101 Life Safety Code Standard (2000 edition), Sections 19.7.5.1 and 10.3.1Smoke barrier doors not fully closing
    • NFPA 701; NFPA 101 Life Safety Code StandardDraperies, curtains, and window coverings flame retardant labeling
    29 Sept 2014Revisit
    Identified deficiencies and documented corrections completed.
    • 483.15(a)
    • 483.20(b)(2)(ii)
    • 483.20(d); 483.20(k)(1)
    • 483.25(a)(3)
    • 483.25(h)
    • 483.60(c)
    • 483.35(i)
    25 Sept 2014Revisit
    Identified several NFPA 101 life-safety-code deficiencies with corrections initiated and largely completed by 08/24/2014, and a follow-up visit occurred on 09/25/2014.
    • 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
    • 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
    25 Sept 2014Revisit
    Investigated follow-up of a prior deficiency; corrections completed.
    10 Jul 2014Complaint
    Investigated a complaint and identified deficiencies related to resident dignity and to assessing significant changes in condition.
    • 483.15(a)DIGNITY AND RESPECT OF INDIVIDUALITY
    • 483.20(b)(2)(ii)COMPREHENSIVE ASSESSMENT AFTER SIGNIFICANT CHANGE
    09 Jul 2014Life Safety
    Identified several life-safety deficiencies during the survey, including missing or non-visible exit signage, improper door hardware/closing provisions, and other egress safety concerns.
    • NFPA 101 Life Safety Code, 2000 EditionEXIT SIGNAGE
    • NFPA 101 Life Safety Code, 2000 EditionDOOR CLOSING/DOOR HARDWARE
    • NFPA 101 Life Safety Code, 2000 EditionTHERAPY GYM DOORS
    • NFPA 101 Life Safety Code StandardLIFE SAFETY CODE – GENERAL
    • NFPA 101 Life Safety Code StandardDOOR LOCKING ARRANGEMENTS
    • NFPA 101 Life Safety Code StandardGENERATORS/LIFE SAFETY SYSTEMS
    • NFPA 101 Life Safety Code StandardDRAPERIES/CURTAINS
    09 Jul 2014Life Safety
    Identified multiple deficiencies related to safety equipment, plumbing, and general facility maintenance during the inspection.
    • ANSI Z358.1; IPC (2006 Edition), Sections on Emergency Eyewash and general plumbingEmergency eyewash equipment not properly maintained
    • IPC (2006 Edition)Handwashing facilities not meeting requirements
    • IPC (2006 Edition)Ice machine drainage and installation concerns
    • IPC (2006 Edition)Kitchen hood/ventilation inadequate
    • IPC (2006 Edition); ANSI Z358.1Exhaust ventilation in certain rooms not adequately installed
    • IPC (2006 Edition); ANSI Z358.1Cross-connection hazards in plumbing
    • IPC (2006 Edition); ANSI Z358.1Water heater relief valve arrangement
    23 May 2013Licensure
    Investigated a deficiency in dietary services supervision; the dietary manager did not meet qualification requirements and is enrolled in a certification program with a completion target by 12/31/2013.
    • Wyoming Department of Health Aging Division Rules and Regulations for Program Administration of Nursing Care Facilities Chapter 11Dietetic Services
    23 May 2013Licensure
    Investigated a deficiency in dietetic services and found that the required rules were not met.
    • Wyoming Rules and Regulations for Program Administration of Nursing Care Facilities Chapter 11; Section 11 Dietetic ServicesDietetic Services
    22 May 2013Life Safety
    Identified multiple life-safety deficiencies including gaps in smoke barriers, sprinkler coverage issues, and improper placement of safety devices.
    • NFPA 101 Life Safety Code Standard; NFPA 101, 2000 Edition; NFPA 25, 1999 EditionSmoke barrier penetrations and barrier inspections
    • NFPA 101 Life Safety Code Standard; NFPA 25Sprinkler system coverage and emergency lighting maintenance
    • NFPA 101 Life Safety Code StandardExtended coverage sprinkler heads and related maintenance
    • NFPA 101 Life Safety Code StandardSpare sprinkler stock and related requirements
    • NFPA 101 Life Safety Code Standard; NFPA 70Identification of Others – electrical wiring
    • NFPA 101 Life Safety Code StandardIdentification of Others – ABHR dispensers
    14 Jun 2012Revisit
    Investigated a follow-up visit related to a prior report. Found multiple deficiencies with corrections completed.
    05 Jun 2012Revisit
    Verified corrections were completed for several life-safety deficiencies cited under the NFPA 101 Life Safety Code.
    • 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
    • NFPA 101 Life Safety CodeLife Safety Code deficiency
    • NFPA 101 Life Safety CodeLife Safety Code deficiency
    12 Apr 2012Licensure
    Investigated the reported concerns and found deficiencies in care planning, nutrition monitoring, resident rights in decision-making, and environmental safety; corrective actions were identified.
    • RIGHT TO PARTICIPATE IN PLANNING AND REVISING CARE
    • PROVISION OF SERVICES MEETING PROFESSIONAL STANDARDS
    • CARE PLANS AND RELATED SERVICES
    • PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING
    • MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE
    • SAFE/FUNCTIONAL/SANITARY/COMFORTABLE ENVIRONMENT
    12 Apr 2012Licensure
    Determined this home was in compliance with state requirements.
    10 Apr 2012Life Safety
    Investigated the complaint and found multiple life-safety deficiencies related to smoke barrier doors, exit signage, locking hardware, testing records, and electrical safety.
    • NFPA 101 LIFE SAFETY CODE STANDARDSelf-closing device and exit signage deficiencies
    • NFPA 101 LIFE SAFETY CODE STANDARDLocking hardware not compliant with egress requirements
    • NFPA 101 LIFE SAFETY CODE STANDARDTesting and records not maintained
    • NFPA 101 LIFE SAFETY CODE STANDARDExit signage deficiencies
    • NFPA 101 LIFE SAFETY CODE STANDARDLiquid oxygen safety and related equipment deficiencies
    • NFPA 101 LIFE SAFETY CODE STANDARDElectrical safety—damaged wiring and covers
    • NFPA 101 LIFE SAFETY CODE STANDARDFire drills not conducted as required
    10 Apr 2012Life Safety
    Investigated deficiencies related to life-safety and maintenance; observed issues included oxygen transfer areas lacking proper separation, a missing junction box cover, and inadequate exit signage.
    • NFPA 101 Life Safety Code StandardTransferring of oxygen
    • NFPA 101 Life Safety Code StandardJunction box and power cord safety
    • NFPA 101 Life Safety Code StandardExit signage
    10 Apr 2012Licensure
    Identified that construction projects lacked required plan approvals from the Wyoming Department of Health; based on record review and interviews, no approvals were obtained.
    • Chapter 19, Section 7 — Construction/Remodeling (Rules for Licensure of Nursing Facilities)Construction/Remodeling plan approvals
    20 Jul 2011Revisit
    Identified multiple deficiencies affecting resident care and safety during the revisit; corrections were completed for many items, with some uncorrected deficiencies reported.
    17 Jun 2011Complaint
    Investigated one complaint; one allegation was confirmed, and no citation was issued due to prior identification and current compliance in this area.
    17 Jun 2011Complaint
    Investigated one complaint; the allegation had merit and no citation was issued due to prior identification and current compliance.
    14 Jun 2011Revisit
    Determined substantial compliance after confirming corrections were completed.
    • Life Safety Code deficiency (NFPA 101) - K0025
    • Life Safety Code deficiency (NFPA 101) - K0029
    • Life Safety Code deficiency (NFPA 101) - K0062
    • Life Safety Code deficiency (NFPA 101) - K0144
    28 Apr 2011Complaint
    Found multiple deficiencies in care planning, resident assessments, and daily operations.
    • Continued From Page 1 - TV relocation area too small
    • Continued From Page 3 - Daily bowel function and bowel assessment
    • Continued From Page 6 - Care plan accuracy
    • 483.26(m)(1)Free of medication error rates of 5% or more
    28 Apr 2011Complaint
    Investigated a complaint involving deficiencies in resident care, nutrition, and monitoring, with multiple incomplete assessments and follow-up actions noted.
    27 Apr 2011Life Safety
    Identified life-safety code deficiencies including improper storage and separation of hazardous areas, gaps in smoke barrier doors, and issues with emergency generator controls; corrective actions were noted.
    • NFPA 101 Life Safety Code StandardHazardous areas not properly separated from use areas
    • NFPA 101 Life Safety Code StandardPlan of Correction – equipment location
    • NFPA 101 Life Safety Code StandardPlan of Correction – ongoing monitoring
    02 Nov 2010Complaint
    Investigated a complaint and found no deficiencies identified during the November 2, 2010 review.
    20 Oct 2010Complaint
    Found no deficiencies identified in the complaint investigation.
    30 Apr 2010Complaint
    Investigated a complaint and determined that the allegation of misappropriation of property and quality of care was unsubstantiated.
    16 Apr 2010Revisit
    Verified corrections completed for previously cited deficiencies; the revisit indicated compliance on multiple items.
    19 Mar 2010Revisit
    Found no deficiencies during the revisit. Follow-up indicated continued compliance.
    25 Feb 2010Licensure
    Investigated deficiencies related to TB testing; two new employees lacked timely tuberculin testing before resident contact, with documentation gaps for others.
    • Wyoming State Rules and Regulations for Nursing Homes Chapter 11 Section 5(b)(iv)(A)Tuberculin testing for employees
    25 Feb 2010Complaint
    Identified deficiencies related to infection control, resident care (toileting and support), use of protective devices, and isolation practices. Noted failures to consistently implement the care plans and prevent cross-contamination.
    • Continued From page 3
    • Continued From page 6
    • Continued From page 8
    • Continued From page 12
    • Continued From page 13
    25 Feb 2010Life Safety
    Identified a life-safety deficiency related to corridor door closures and hardware that did not meet the standard.
    • NFPA 101 Life Safety Code StandardLife Safety Code Standard
    22 Apr 2009Life Safety
    The review identified several life-safety deficiencies, including inadequate inspection of corridor doors, problems with smoke barrier integrity and construction, and issues with fire drills, sprinkler coverage, electrical systems, and signage.
    • NFPA 101 Life Safety Code Standard 19.3.2.1Corridor doors inspection
    • NFPA 101 Life Safety Code Standard 8.3; 19.3.7.3; 19.3.7.5; 19.1.6.3; 19.1.6.4Smoke barriers and fire-resistance
    • NFPA 101 Life Safety Code Standard 19.3.2.1Penetrations/inspections of smoke barriers
    • NFPA 101 Life Safety Code Standard 19.3.2.1Fire drills timing
    • NFPA 101 Life Safety Code Standard 9.7.5; 9.7.3; 9.7.4Sprinkler coverage
    • NFPA 101 Life Safety Code Standard 19.3.2.1; NFPA 99; NFPA 70Non-smoking signs and electrical signage
    • NFPA 70 National Electrical CodeElectrical wiring and equipment
    13 Feb 2009Revisit
    Investigated prior deficiencies and corrections were completed.
    • 483.15(h)(2)
    • 483.20(k)(3)(i)
    • 483.20(k)(3)(ii)
    • 483.25(a)(3)
    • 483.25(d)
    • 483.20(k)(3)(ii)
    • 483.65(b)(3)
    • 483.35(i)
    • 483.40(b)
    • 483.60(c)
    30 Jan 2009Revisit
    Verified corrections completed for previously identified deficiencies after follow-up.
    11 Dec 2008Complaint
    Found deficiencies in care planning, daily living support, sanitation, and infection control, indicating non-compliance with several requirements.
    • 483.20(k)(3)(i)COMPREHENSIVE CARE PLANS
    • 483.20(k)(3)(ii)COMPREHENSIVE CARE PLANS
    • 483.25(h)ACTIVITIES OF DAILY LIVING
    • 483.65(i)SANITARY CONDITIONS
    • 483.60(c)DRUG REGIMEN REVIEW
    • 483.65(b)(3)PREVENTING SPREAD OF INFECTION
    11 Dec 2008Life Safety
    Identified multiple life-safety and facility issues, including unsealed ceiling penetrations, gaps around fixtures, smoke‑partition concerns, and deficiencies in fire drills and electrical wiring.
    • 42 CFR 483.70(a); NFPA 101 Life Safety Code StandardSmoke compartments and Life Safety Code compliance
    • NFPA 101 Life Safety Code StandardGaps and penetrations compromising fire containment
    • NFPA 70; NFPA 101 Life Safety Code StandardElectrical wiring and protection; self-closure device
    27 Sept 2007Complaint
    Determined that no deficiencies were identified in the complaint investigation.
    20 Jul 2007Complaint
    Investigated a complaint and found no deficiencies identified.
    23 Mar 2007Complaint
    Investigated a complaint and found no deficiencies.
    04 Mar 2007Revisit
    Found no deficiencies. All identified issues were corrected.
    04 Jan 2007Revisit
    Identified regulatory deficiencies and verified the necessary corrections were completed.
    • 483.15(a)Regulatory deficiency cited
    04 Jan 2007Revisit
    Investigated and found no deficiencies.
    28 Nov 2006Revisit
    Identified life-safety deficiencies were cited and later corrected after a follow-up visit.
    • NFPA 101 Life Safety CodeLife Safety Code deficiency
    • NFPA 101 Life Safety CodeLife Safety Code deficiency
    • NFPA 101 Life Safety CodeLife Safety Code deficiency
    28 Nov 2006Revisit
    Investigated the follow-up after a prior survey; noted that a summary of uncorrected deficiencies was sent.
    12 Oct 2006Complaint
    An investigation found multiple deficiencies spanning dignity, care planning, and infection control, along with sanitation and resident management issues that affected the care provided.
    • 483.15(a)DIGNITY
    • 483.20(d), 483.20(k)(1)COMPREHENSIVE CARE PLANS
    • 483.25(c)PRESSURE SORES
    • 483.25(h)(2)URINARY INCONTINENCE
    • 483.35(i)(2)SANITARY CONDITIONS - FOOD PREP & SERVICE
    • 483.65(a)INFECT CONTROL
    • 483.65(b)(1)PREVENTING SPREAD OF INFECTION
    • 483.65(b)(2)PLAN OF CORRECTION
    12 Oct 2006Licensure
    Identified noncompliance with staff tuberculosis testing requirements; two employees began work before TB tests were completed and documented.
    • Rules and Regulations for Program Administration of Nursing Care Facilities, Section 5. Organization and Administration, (b)(iv)(A) Tuberculin testing shall be accomplished for each employee upon employment and before resident contact begins and annually thereafter.Tuberculin testing requirements for employees
    03 Oct 2006Life Safety
    Found multiple life-safety code deficiencies involving corridor door construction, exit access, and electrical wiring. Identified issues across several life-safety standards during a regulatory review.
    • NFPA 101 Life Safety Code StandardDoor openings in corridor protections
    • NFPA 101 Life Safety Code StandardLife safety: fire-resistance of construction and protection of hazardous areas
    • NFPA 101 Life Safety Code StandardExit access readily accessible
    • NFPA 101 Life Safety Code StandardElectrical wiring and equipment installation
    02 Nov 2005Revisit
    Investigated and found no deficiencies.
    01 Nov 2005Revisit
    Identified deficiencies requiring correction and follow-up; uncorrected deficiencies were documented.
    22 Sept 2005Licensure
    Identified deficiencies in dietary services; 11 of 16 residents described meals as bland and institutional, indicating meals were not palatable.
    • 483.35 DIETARY SERVICESDIETARY SERVICES
    07 Sept 2005Life Safety
    Identified deficiencies related to emergency lighting testing and oxygen storage/ventilation, with corrective actions planned.
    • NFPA 101 Life Safety Code StandardEmergency lighting testing
    • NFPA 99 Section 8-6.2.5.2.2Oxygen storage
    • NFPA 99 Section 8-6.2.5.2Oxygen storage/ventilation
    13 Jun 2005Complaint
    Investigated a complaint and found no deficiencies.

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