Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wyoming Retirement Center during CMS and state inspections, most recent first.
Bed rail use was identified for 4 sampled residents without documented entrapment risk assessments, review of benefits and hazards with the resident or representative, or informed consent. Observations showed bilateral bed enablers or built-in rails in place, with measured gaps and openings in the rail structures, while the unit manager confirmed the facility did not assess entrapment risk and had no signed consents on file.
Failure to Offer and Document Flu and Pneumococcal Vaccinations: Review of 5 sampled residents showed missing evidence that flu and pneumococcal vaccines were offered or provided. Records showed one resident marked not eligible for flu vaccine without a date, others documented as refusing PCV-20 and/or influenza without dates, and one resident with a prior flu shot but no evidence of annual follow-up or pneumococcal vaccination. The DON/administrator stated the facility had no evidence residents were offered immunizations annually, despite policy requiring annual flu offers and pneumococcal offers on admission and as new vaccines were recommended.
Failure to Offer and Document COVID-19 Vaccination: The facility failed to offer and/or provide the 2025-2026 COVID-19 vaccine to 5 sampled residents. MR review showed some residents had prior COVID vaccine doses documented, while others had refusals without a date the vaccine was offered and declined. The administrator stated there was no evidence residents were offered immunizations, despite the facility policy requiring COVID-19 vaccines to be offered on admission and as new vaccines are recommended.
Improper Labeling of Insulin Pens and Opened Multi-Dose Medications: A facility failed to properly label resident insulin pens and an opened multi-dose insulin pen in the North med room. One pen was stored with other residents' insulin pens and identified only by handwritten tape, while another opened pen lacked the open date, expiration date, and discard-by date. The unit manager confirmed the pens were not labeled per facility standards, and the med labeling policy required full resident identification and dating of opened multi-dose meds.
A resident with severe cognitive impairment and physical dependency was struck on the leg by another resident's cane, causing a bruise, after the aggressor yelled and swung the cane during an altercation. The incident was documented by staff, and both residents confirmed the contact, with the aggressor later admitting to the action. The facility's policy prohibits abuse, but this event resulted in actual physical harm.
The facility failed to protect residents from abuse, resulting in physical and mental harm. A CNA engaged in a verbal altercation with a cognitively impaired resident, using profanity and intimidation. Another resident with Alzheimer's was physically harmed by a fellow resident. Additional incidents involved residents with severe cognitive impairments engaging in physical altercations, highlighting inadequate supervision and protection.
Two residents suffered harm due to the facility's failure to prevent accidents and ensure safety. One resident, with severe cognitive impairment, was injured during a transfer without a gait belt, resulting in a hip fracture. Another resident, also cognitively impaired, was found outside after a door alarm went off, leading to injuries from prolonged exposure. The facility's policies on transfers and door alarms were not adequately followed or detailed.
The facility failed to report abuse allegations timely for three residents. One resident was involved in a physical altercation, another felt threatened by a tablemate, and a third was threatened by a roommate. These incidents were not reported as required by the facility's policy.
The facility failed to investigate abuse allegations for two residents. One resident felt threatened by a tablemate's mean comments and threats, leading them to eat in their room. Another resident felt unsafe due to a roommate's threats and was moved after a near-physical altercation. Despite the facility's policy requiring investigations, none were conducted.
A resident with severe cognitive impairment and a history of fractures was injured during a transfer when a CNA failed to use a gait belt as required by the care plan and facility policy. The resident lost balance and suffered a hip fracture, leading to severe pain and emergency department evaluation. Staff interviews confirmed the non-use of the gait belt, despite training and policy requirements.
A facility failed to monitor target symptoms for a resident receiving psychotropic medications and did not limit PRN orders for another resident with severe cognitive impairment. The first resident, with moderate cognitive impairment and multiple diagnoses, was not monitored for specific target symptoms to evaluate medication effectiveness. The second resident had a PRN lorazepam order without an end date, and no physician rationale was documented for extending the order beyond 14 days, despite receiving the medication 18 times over two months.
Two residents with moderate cognitive impairment experienced verbal abuse and threats from other residents with intact cognition. One resident was repeatedly insulted and threatened, causing emotional distress, while another was threatened with violence by their roommate, leading to a room change for safety.
A resident with intact cognition was harmed by another resident with severe cognitive impairment in an LTC facility. The incident involved a water cup being thrown, causing physical harm and fear. Immediate actions were taken to separate the residents, but staff training on de-escalation was incomplete, and the incident had not been reviewed in a quality assurance meeting.
Bed Rail Use Without Entrapment Assessment or Informed Consent
Penalty
Summary
The facility failed to ensure entrapment risk was assessed, the risks and benefits of bed rails were reviewed with the resident or representative, and informed consent was obtained before bed rails were installed for 4 of 4 sampled residents (#1, #6, #9, and #25) reviewed for bed rail use. Observations showed each of these residents had bilateral bed enablers or bed rails attached to the bed frame, including resident #1 with a 1-inch gap between the mattress and enabler and openings within the rail structure, resident #25 with a 2-inch gap and large top and bottom openings, resident #9 with bilateral bed enablers measuring 4 1/2 x 6 inches, and resident #6 with built-in bed rails measuring 4 inches x 8 inches and a 2-inch gap between the rail and mattress. Review of the medical records for all 4 residents showed no evidence that a clinical assessment had been completed to determine entrapment risk, and there was no documentation of informed consent or of the benefits and hazards of bed rails being reviewed with the resident or resident representative. The North unit manager confirmed the facility did not assess residents for risk of entrapment in bed rails and did not have signed consents on file for bed rail use. The facility policy titled Bed Safety and Bed Rails, last updated August 2022, stated that the resident assessment includes factors such as diagnosis, size and weight, sleep habits, medications, cognition, mobility, and fall risk, and that staff shall inform the resident or representative about the benefits and potential hazards of bed rails and obtain informed consent before use.
Failure to Offer and Document Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer and/or provide influenza and pneumococcal vaccinations to 5 of 5 sampled residents reviewed for immunization status. Medical record review showed resident #12 was admitted to the facility and was marked not eligible for the influenza vaccination, with no date indicated, and there was no evidence the resident was offered or received an annual influenza vaccination. Resident #29 was admitted to the facility, had received PCV-23 on 4/24/2012, refused PCV-20 on 9/23/23, and was documented as refusing the influenza vaccination with no date indicated; however, there was no evidence the resident was offered or received PCV-20 since 9/23/23 and no evidence of an annual influenza vaccination. Medical record review also showed resident #36 and resident #56 were documented as refusing PCV-20 and influenza vaccinations with no date indicated, but there was no evidence either resident was offered or received PCV-20 or an annual influenza vaccination. Resident #9 had last received the influenza vaccination on 10/3/24, but there was no evidence the resident was offered or received an annual influenza vaccination since that date and no evidence the resident was offered or received a pneumococcal vaccination. The administrator stated on 6/29/26 that the facility did not have evidence residents were offered immunizations annually. The facility policy titled Vaccines dated 4/29/21 stated residents and staff without medical contraindications would be offered flu vaccines annually between October 1st and March 31st, and residents would be offered pneumococcal and COVID-19 vaccines on admission and as new vaccines were recommended.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to offer and/or provide the 2025-2026 COVID-19 vaccine to 5 of 5 sampled residents reviewed for immunization status. Medical record review showed resident #12 had a last documented COVID vaccine dose on 3/31/24, resident #36 had a last documented dose on 6/30/22, and resident #9 had a last documented dose on 5/5/21, with no evidence that any of these residents were offered or received the 2025-2026 COVID vaccine. Medical record review also showed residents #29 and #56 had refused the COVID vaccine, but their records did not indicate a date when the vaccine was offered and declined. Review of CDC 2025-2026 COVID-19 vaccination guidance dated 11/4/25 showed recommendations for unvaccinated individuals to receive 2 doses of the 2025-2026 vaccine, with the second dose 4-8 weeks after the first, and for individuals who completed the initial series to receive 1 dose at least 8 weeks after the last dose. During interview on 6/29/26 at 4:31 PM, the administrator stated the facility did not have evidence residents were offered immunizations. Review of the facility policy titled Vaccines dated 4/29/21 stated residents and staff would be offered COVID-19 vaccines on admission and as new vaccines are recommended.
Improper Labeling of Insulin Pens and Opened Multi-Dose Medications
Penalty
Summary
The facility failed to properly label and identify resident medications and failed to label opened multi-dose vials with the expiration and discard dates in 1 of 5 medication storage areas, the North medication room. During observation on 6/30/26 at 3:18 PM, resident #23's Insulin Aspart pen was stored in a communal plastic container with other residents' insulin pens. The pen did not have a formal pharmacy dispensing label and was identified only by the resident's first name handwritten on medical tape. The pen had an expiration date of 8/31/26 and an open date of 6/22/26, but no discard-by date 28 days after opening. The same observation showed an Insulin Glargine pen assigned to resident #10 that had been opened and accessed but did not have an open date, expiration date, or discard-by date. During interview on 6/30/26 at 5:23 PM, the North unit manager stated all insulin pens should have a complete pharmacy label with the resident's full name and that opened multi-dose insulin pens must be labeled with the date opened, calculated discard date, and initials of the nurse who opened it. Review of the facility policy titled Medication Labeling and Storage, dated 2/2023, showed that medication labels must include required identifying information and that opened multi-dose vials are to be dated and discarded within 28 days unless the manufacturer specifies otherwise.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Harm
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. One resident with severe cognitive impairment and physical dependency was struck on the right lower leg by another resident's cane, resulting in a bruise. The incident occurred when the resident was being assisted to the bathroom by a CNA, and the other resident, who had a history of physical and verbal behaviors directed at others, approached, yelled, and swung the cane. Documentation confirmed the injury, and both residents acknowledged the contact, with the aggressor initially denying but later admitting to the action. Staff interviews revealed uncertainty about whether the altercation was directly witnessed, but the injury was observed and reported. The facility's incident report and medical assessments documented the event and the resulting harm. The facility's policy states that all residents will be protected from abuse and neglect, but the incident demonstrated a failure to prevent resident-to-resident physical abuse, resulting in actual harm.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in both physical and mental harm. In one incident, a CNA engaged in a verbal altercation with a resident who had severe cognitive impairment. The resident, who had a history of non-Alzheimer's dementia and depression, followed the CNA, leading to a confrontation where the CNA used profanity and physical intimidation. Despite attempts by other staff to intervene, the CNA continued to pursue the resident, escalating the situation. The CNA was eventually terminated, but the incident highlighted a failure to maintain a safe environment for the resident. In another incident, a resident with Alzheimer's disease and memory impairment was physically harmed by another resident. The aggressor, who also had severe cognitive impairment, entered the victim's room and struck them, leaving a mark on the victim's face. The facility's response involved monitoring the victim for signs of distress, but the incident underscored a lack of adequate supervision and intervention to prevent resident-to-resident altercations. Additional incidents involved residents with severe cognitive impairments engaging in physical altercations with other residents, resulting in harm and distress. In one case, a resident was struck with a garbage can by another resident, and in another, a resident was hit in the head during an altercation. These events demonstrate a pattern of inadequate protection and supervision, leading to repeated instances of abuse and harm among residents.
Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure the safety of residents, resulting in harm to two residents. Resident #48, who had severe cognitive impairment and was dependent on staff for transfers, suffered a right hip intertrochanteric fracture during a transfer from a wheelchair to a bed. The CNA assisting the resident did not use a gait belt as required by facility policy, and the resident lost balance, hitting the wheelchair armrest. Despite the resident's severe pain, the nurse initially administered scheduled pain medication before sending the resident to the emergency department upon the family's request. Interviews revealed that staff were educated on using gait belts, but the policy was not followed during this incident. Resident #78, also with severe cognitive impairment and a history of wandering, was found outside the facility after the door alarm went off. The resident was outside for an extended period, resulting in wet clothing, skin abrasions, and a bruised toe. The facility's policy did not adequately address procedures for responding to door alarms, and staff failed to perform a headcount or realize the resident was missing. The administrator admitted that the policy lacked specific steps for when doors were alarmed, and there was no clear video footage of the resident's movements.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to ensure timely reporting of abuse allegations for three residents. In the first incident, a resident became verbally aggressive over a meal and later accused another resident of running into them with a wheelchair, leading to a physical altercation. This incident was not reported until nine days later. In the second case, a resident expressed discomfort and fear due to mean comments from a tablemate, which led to the resident eating in their room. The facility treated this as a grievance rather than an abuse allegation, and it was not reported to the state survey agency. In the third incident, a resident expressed feeling unsafe due to threats from a roommate, which included a threat to break their neck. The resident was moved to a different room following a verbal altercation that nearly turned physical. Despite the severity of the threats, this incident was not reported as an abuse allegation. The facility's policy requires immediate reporting of such incidents, but the review showed no evidence of compliance with this policy.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure thorough investigations of abuse allegations for two residents. Resident #33 reported feeling threatened by a tablemate who made mean comments and suggested self-harm, leading the resident to eat meals in their room instead of the dining area. Despite the resident's distress and the incident being reported to management, the facility did not conduct an investigation into the allegations, as confirmed by the administrator. Similarly, Resident #24 expressed feeling unsafe due to threats from a roommate, including a threat to break their neck. The resident was moved to a different room following a verbal altercation that nearly became physical. Despite the severity of the threats and the resident's fear, the facility did not perform an internal investigation into the incident, as confirmed by the administrator. The facility's policy requires investigations into such allegations, but no evidence of investigations was found in either case.
Failure to Use Gait Belt Results in Resident Injury
Penalty
Summary
The facility failed to implement treatment in accordance with the care plan for a resident with severe cognitive impairment, who was dependent on staff for all transfers using a gait belt. The resident, who had a history of a right femur fracture, atrial fibrillation, and dementia, experienced an incident during a transfer from a wheelchair to a bed. The CNA assisting the resident did not use a gait belt as required by the care plan and facility policy. During the transfer, the resident attempted to adjust their brief, causing a loss of balance and resulting in the resident sitting hard on the wheelchair's armrest. This incident led to severe pain and an eventual diagnosis of a right hip intertrochanteric fracture. Interviews with facility staff revealed that the CNA did not use a gait belt during the transfer, contrary to the facility's policy and training requirements. The LPN on duty assessed the resident after the incident and administered pain medication, which did not alleviate the resident's pain. Consequently, the resident was sent to the emergency department for further evaluation. The facility's policy mandates the use of gait belts for all transfers, and staff are trained on this procedure during orientation, annually, and when non-compliance is observed.
Failure to Monitor Psychotropic Medications and Limit PRN Orders
Penalty
Summary
The facility failed to ensure that target symptoms were identified and monitored for a resident with moderate cognitive impairment and multiple diagnoses, including depression and schizophrenia. The resident was receiving antipsychotic and antidepressant medications, but the facility did not identify specific target symptoms to evaluate the effectiveness of these medications. The care plan required monitoring for side effects and effectiveness every shift, but there was no evidence in the medical record that this was done. The administrator confirmed that specific target symptoms for the psychotropic medications were not identified. Additionally, the facility did not limit PRN orders for psychotropic medications to 14 days for a resident with severe cognitive impairment and multiple behavioral symptoms. The resident had a PRN order for lorazepam without an end date, and there was no physician documentation or rationale for extending the PRN order beyond 14 days. The resident received the PRN lorazepam 18 times over two months. The DON and MDS coordinator acknowledged the need for a physician rationale to continue a PRN psychotropic medication order beyond 14 days but had not realized the oversight for this resident.
Verbal Abuse and Threats Among Residents
Penalty
Summary
The facility failed to protect residents from verbal abuse, resulting in psychosocial harm to two residents. Resident #5, who had moderate cognitive impairment, was verbally abused by Resident #6, who had no cognitive impairment and a diagnosis of schizophrenia. On one occasion, Resident #6 yelled derogatory remarks at Resident #5, causing emotional distress and fear. This behavior was reportedly a daily occurrence, and Resident #5 expressed ongoing anxiety and fear of Resident #6 in the days following the incident. In another incident, Resident #7, also with moderate cognitive impairment, was threatened by their roommate, Resident #8, who had intact cognition. Resident #8 made a threatening statement about shooting Resident #7, which caused Resident #7 to feel scared and unsafe in their room. As a result, Resident #7 requested and was moved to a different room to avoid further confrontation. The facility's policy on resident abuse and neglect was reviewed, which stated that residents have the right to be free from abuse. However, the incidents involving Residents #5 and #7 indicate a failure to uphold this policy, as both residents experienced verbal aggression and threats from other residents, leading to emotional distress and fear.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in physical and psychosocial harm. Resident #1, who had intact cognition, reported that Resident #2, who had severe cognitive impairment and a diagnosis of dementia, threw a water cup at them, causing a scratch on the face and soaking them with water. The incident was confirmed by staff, and Resident #1 expressed fear of returning to their room, indicating a significant impact on their sense of safety and well-being. The facility's investigation concluded that a physical altercation occurred, and immediate actions were taken to separate the residents, including a temporary room move for Resident #1 and relocating Resident #2 to a private room. Despite these actions, the facility had not completed staff training on triggers, communication, and de-escalation, and the incident had not been reviewed in a quality assurance meeting, which was scheduled for a later date.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Basin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Worland Health And Rehabilitation | 24.6 mi | ★★★★★ | 12 | 1 |
| New Horizons Care Center | 36.5 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.