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
Schedule a Tour
Reviews
3.62·(26)
Overall rating
5
4
3
2
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
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 number
nh-213
Facility type
Nursing Home
Inspection Reports
154
Reports
7
Type A Citations
0
Type B Citations
76
Complaints
21
Years
03 Mar 2025Revisit
03 Mar 2025Revisit
Verified previous deficiencies were corrected and no new noncompliance was found.
15 Jan 2025Complaint
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
13 Jan 2025Revisit
Determined that all prior deficiencies were corrected and no new violations were found. Revisit confirmed compliance.
13 Jan 2025Revisit
13 Jan 2025Revisit
Verified that all previously cited deficiencies were corrected and no new noncompliance was found.
07 Nov 2024Revisit
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
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
09 Oct 2024Revisit
Verified compliance with all life safety requirements; no deficiencies were found.
13 Sept 2024Complaint
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
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
28 May 2024Revisit
Verified compliance with life safety requirements; prior deficiencies were corrected and no new noncompliance was found.
03 May 2024Revisit
03 May 2024Revisit
Found no deficiencies and determined continued compliance after a revisit.
03 May 2024Revisit
03 May 2024Revisit
Verified that all deficiencies were corrected and no new noncompliance was found.
04 Apr 2024Licensure
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
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
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
23 Feb 2024Complaint
Concluded that no deficiencies were identified during the complaint investigation.
21 Dec 2023Complaint
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
21 Nov 2023Revisit
Found no deficiencies.
08 Nov 2023Revisit
08 Nov 2023Revisit
Found no deficiencies; prior deficiencies were corrected.
24 Oct 2023Complaint
24 Oct 2023Complaint
Found no deficiencies identified in relation to the complaint investigation.
05 Oct 2023Complaint
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.
Concluded the provider met state requirements. No deficiencies were cited.
03 Oct 2023Life Safety
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
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
03 Aug 2023Complaint
Found no deficiencies pertaining to the complaint investigation.
29 Jun 2023Revisit
29 Jun 2023Revisit
Verified prior deficiencies were corrected and no new noncompliance was found.
12 May 2023Complaint
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
19 Apr 2023Revisit
Verified compliance after a follow-up survey; no deficiencies were cited.
14 Mar 2023Revisit
14 Mar 2023Revisit
Concluded that all previously cited deficiencies were corrected and compliance restored.
08 Feb 2023Life Safety
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 101 19.5.1; 9.1.2; NFPA 99 6.4.1; NFPA 110 5.1.4Electrical Systems - Other
08 Feb 2023Licensure
08 Feb 2023Licensure
Investigated findings showed multiple deficiencies across rights, care planning, medication management, safety, infection control, and immunizations during the survey.
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
08 Feb 2023Licensure
Concluded no deficiencies were found and state requirements were met.
22 Dec 2022Complaint
22 Dec 2022Complaint
Found no deficiencies identified during the complaint investigation conducted in December 2022.
03 Nov 2022Complaint
03 Nov 2022Complaint
Found no deficiencies identified related to the complaints.
02 Nov 2022Revisit
02 Nov 2022Revisit
Verified that previously cited deficiencies were corrected and found no new noncompliance.
02 Sept 2022Complaint
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
Concluded no deficiencies; all previous deficiencies were corrected on the revisit.
30 Mar 2022Complaint
30 Mar 2022Complaint
Investigated the complaint and found no deficiencies.
18 Mar 2022Complaint
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
18 Jan 2022Revisit
Verified all previous deficiencies were corrected and no new noncompliance was found.
29 Dec 2021Revisit
29 Dec 2021Revisit
Verified deficiencies were corrected and compliance restored.
24 Nov 2021Life Safety
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
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 483.15(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
18 Nov 2021Licensure
Concluded compliance with state requirements following a licensure survey. No deficiencies were cited.
06 Aug 2021Complaint
06 Aug 2021Complaint
Found no deficiencies. The complaint intake review and a COVID-19 focused infection control review identified no deficiencies.
22 Jul 2021Revisit
22 Jul 2021Revisit
Verified no deficiencies were found on follow-up. All previously cited deficiencies were corrected.
20 May 2021Complaint
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
08 Apr 2021Revisit
Verified that all prior deficiencies were corrected and found no new noncompliance.
16 Feb 2021Complaint
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
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
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
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
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
23 Dec 2019Revisit
Found no deficiencies. All regulations surveyed were in compliance.
09 Dec 2019Revisit
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
13 Nov 2019Revisit
Verified no deficiencies related to emergency preparedness and confirmed compliance with all applicable rules.
15 Oct 2019Licensure
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
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
10 Oct 2019Licensure
Identified multiple deficiencies across grievances, abuse reporting/investigation, care planning, pharmacy, dietary staffing, menus, and infection control.
§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
10 Oct 2019Licensure
Concluded compliance with state requirements. No deficiencies were cited.
07 Oct 2019Revisit
07 Oct 2019Revisit
Verified prior deficiencies were corrected and no new noncompliance was found; overall compliance with regulations.
27 Aug 2019Complaint
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
07 Aug 2019Revisit
Verified compliance with all regulations; previous deficiencies were corrected and no new noncompliance found.
04 Jun 2019Complaint
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
10 Dec 2018Revisit
Verified all prior deficiencies were corrected and no new noncompliance was found.
10 Dec 2018Revisit
10 Dec 2018Revisit
Confirmed compliance with all regulations surveyed; prior deficiencies corrected and no new noncompliance found.
22 Oct 2018Revisit
22 Oct 2018Revisit
Investigated the previous deficiencies and confirmed all were corrected. No new noncompliance was found.
13 Sept 2018Licensure
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
13 Sept 2018Complaint
Found deficiencies related to resident rights, care monitoring, and record-keeping during the inspection.
12 Sept 2018Life Safety
12 Sept 2018Life Safety
Investigated deficiencies in emergency preparedness and safety related to kitchen-dining area access and missing volunteer procedures during emergencies.
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—
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20 Apr 2018Complaint
20 Apr 2018Complaint
Identified deficiencies in meal safety and resident nutrition, with past noncompliance noted.
Type A—Continued From page 1
05 Apr 2018Revisit
05 Apr 2018Revisit
Identified no deficiencies.
08 Mar 2018Complaint
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
08 Mar 2018Revisit
Verified that all previously cited deficiencies were corrected during the follow-up.
18 Jan 2018Complaint
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
05 Dec 2017Complaint
Investigated a complaint survey conducted from 12/04/2017 to 12/05/2017 and found no deficiencies.
16 Nov 2017Revisit
16 Nov 2017Revisit
Found no deficiencies. A follow-up survey showed all previous deficiencies corrected and compliance with the surveyed regulations.
08 Nov 2017Revisit
08 Nov 2017Revisit
Verified that all previous deficiencies were corrected and no new noncompliance was found.
14 Sept 2017Complaint
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
14 Sept 2017Licensure
Found no deficiencies; the survey determined compliance with state requirements.
13 Sept 2017Life Safety
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), 19.3.5.12; 7.2.1.2; NFPA 10Monitoring/compliance with portable fire extinguishers
25 Jan 2017Revisit
25 Jan 2017Revisit
Investigated the revisit; found no deficiencies.
06 Dec 2016Revisit
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
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
14 Nov 2016Revisit
Investigated the revisit and found no deficiencies.
14 Nov 2016Revisit
14 Nov 2016Revisit
Verified corrections to previously cited deficiencies were completed. Follow-up confirmed ongoing compliance.
08 Nov 2016Life Safety
08 Nov 2016Life Safety
Investigated a Life Safety Code licensure complaint; found no deficiencies.
13 Oct 2016Complaint
13 Oct 2016Complaint
Investigated a complaint survey conducted from 2016-10-12 to 2016-10-13 and found no deficiencies.
22 Sept 2016Complaint
22 Sept 2016Complaint
Investigated and found deficiencies related to safety hazards, sanitation, and maintenance in several areas.
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22 Sept 2016Licensure
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.
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
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
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
14 Sept 2016Revisit
Found no deficiencies cited during the revisit.
29 Jul 2016Complaint
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
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
09 Nov 2015Revisit
Verified corrections completed for previously identified deficiencies.
Investigated and verified corrections completed for prior deficiencies.
20 Aug 2015Licensure
20 Aug 2015Licensure
Investigated a dietary management concern and found the dietary manager was not certified or qualified.
—Dietary Manager Qualification
20 Aug 2015Complaint
20 Aug 2015Complaint
Identified deficiencies in sanitation and care quality, including housekeeping, nutrition, and food service practices, with corrective actions planned.
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
03 Aug 2015Complaint
Investigated a complaint and found no deficiencies.
23 Jul 2015Life Safety
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
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
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
25 Sept 2014Revisit
Investigated follow-up of a prior deficiency; corrections completed.
10 Jul 2014Complaint
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
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
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
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
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
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
14 Jun 2012Revisit
Investigated a follow-up visit related to a prior report. Found multiple deficiencies with corrections completed.
05 Jun 2012Revisit
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
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
12 Apr 2012Licensure
Determined this home was in compliance with state requirements.
10 Apr 2012Life Safety
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
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
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
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
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
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
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
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
28 Apr 2011Complaint
Investigated a complaint involving deficiencies in resident care, nutrition, and monitoring, with multiple incomplete assessments and follow-up actions noted.
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27 Apr 2011Life Safety
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
02 Nov 2010Complaint
Investigated a complaint and found no deficiencies identified during the November 2, 2010 review.
20 Oct 2010Complaint
20 Oct 2010Complaint
Found no deficiencies identified in the complaint investigation.
30 Apr 2010Complaint
30 Apr 2010Complaint
Investigated a complaint and determined that the allegation of misappropriation of property and quality of care was unsubstantiated.
16 Apr 2010Revisit
16 Apr 2010Revisit
Verified corrections completed for previously cited deficiencies; the revisit indicated compliance on multiple items.
19 Mar 2010Revisit
19 Mar 2010Revisit
Found no deficiencies during the revisit. Follow-up indicated continued compliance.
25 Feb 2010Licensure
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
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
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
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
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
30 Jan 2009Revisit
Verified corrections completed for previously identified deficiencies after follow-up.
11 Dec 2008Complaint
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
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
27 Sept 2007Complaint
Determined that no deficiencies were identified in the complaint investigation.
20 Jul 2007Complaint
20 Jul 2007Complaint
Investigated a complaint and found no deficiencies identified.
23 Mar 2007Complaint
23 Mar 2007Complaint
Investigated a complaint and found no deficiencies.
04 Mar 2007Revisit
04 Mar 2007Revisit
Found no deficiencies. All identified issues were corrected.
04 Jan 2007Revisit
04 Jan 2007Revisit
Identified regulatory deficiencies and verified the necessary corrections were completed.
483.15(a)Regulatory deficiency cited
04 Jan 2007Revisit
04 Jan 2007Revisit
Investigated and found no deficiencies.
28 Nov 2006Revisit
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
28 Nov 2006Revisit
Investigated the follow-up after a prior survey; noted that a summary of uncorrected deficiencies was sent.
12 Oct 2006Complaint
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
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
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
02 Nov 2005Revisit
Investigated and found no deficiencies.
01 Nov 2005Revisit
01 Nov 2005Revisit
Identified deficiencies requiring correction and follow-up; uncorrected deficiencies were documented.
22 Sept 2005Licensure
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
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
Investigated a complaint and found no deficiencies.
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