Citations in Wyoming
Statistics, citations and compliance trends for long-term care facilities in Wyoming.
Statistics for Wyoming (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Wyoming
Cold Main Dining Room Temperature: The facility failed to maintain comfortable and safe temperatures in the main dining room, which was repeatedly reported by residents as cold during meals. Observations found residents using coats and blankets in the dining room, and measured temperatures were below the facility’s 71 to 81 degree range, including readings of 68.6 degrees, 66.8 degrees, and an air vent blowing 46-degree air into the room.
A resident with severe cognitive impairment was physically assaulted by another resident who also had severe cognitive impairment and a care plan for aggressive behaviors toward others. In the atrium, after the resident asked the other resident to move away, the other resident pushed the resident in the abdomen, causing a fall, wrist pain, swelling, bruising, unresponsiveness, and ER-confirmed fractures of both distal radii and the ulna styloid; an LPN and CNA witnessed the event, and the DON stated staff were expected to redirect and follow care plans.
Failure to notify a resident representative of a change in condition: A resident with severe cognitive impairment, Alzheimer’s dementia, DM, and urinary incontinence developed a coccyx wound that was treated and monitored by nursing staff, but the resident’s representative was not notified before the wound was discussed at the care plan conference. The wound care nurse, the representative, and the DON all confirmed the lack of prior notification.
Failure to protect a resident with severe cognitive impairment from physical abuse by another resident. A resident with a history of agitation and physical aggression punched another resident in the face multiple times and attempted to wrap the resident's O2 tubing around the resident's neck after a confrontation near the wheelchair. Staff intervened before the tubing was placed around the neck, and the assaulted resident had redness to the cheek while the aggressive resident had broken skin on the knuckles.
The facility failed to provide enough nursing staff and did not maintain adequate CNA coverage across multiple shifts. The DON stated the schedule was built with 2 nurses per shift and a minimum CNA pattern, but survey review of PBJ data, worked schedules, and staffing declarations showed repeated shortages, including shifts with only 1 CNA overnight and other shifts with 2 to 3 CNAs. Residents and the resident council reported long call light times, delayed or missing food delivery, and difficulty getting clothing changed, and a CNA reported feeling overwhelmed by low staffing.
Failure to Provide Written Transfer/Discharge Notice: The facility did not provide written transfer/discharge notices before hospital transfers for multiple residents. The DON stated that an Interact form was sent with residents and bed-hold information was provided, but confirmed that residents or their representatives were not given the required written notice. The facility policy required a Resident Notice of Transfer or Discharge with specific information, including the reason for transfer, destination, and Ombudsman contact information.
Cold Main Dining Room Temperature
Penalty
Summary
The facility failed to ensure comfortable and safe temperature levels in 1 of 2 dining areas, the main dining room, where the temperature was found below the facility’s stated range of 71 to 81 degrees Fahrenheit. Resident interviews indicated the dining room was sometimes cold, especially during meals, and one resident reported the air conditioner was run all the time in the dining room. Another resident stated the dining room was cold and staff had to provide something for his/her shoulders during meals. During the resident council meeting, six residents reported that the dining room and hallways were always cold. Observation on 6/15/26 showed the main dining room felt cold, with 9 residents present; 1 resident wore a coat, 1 had a blanket around his/her shoulders, and 2 residents had blankets on their laps. Later observations showed the dining room felt much colder than the area outside it, and temperatures measured in the main dining room were 68.6 degrees Fahrenheit near the kitchen and 66.8 degrees Fahrenheit at table height closest to the kitchen. The air vent closest to the kitchen was measured at 46 degrees Fahrenheit blowing into the dining room. The maintenance director confirmed the temperature was colder than 71 degrees Fahrenheit. The facility policy stated it would maintain comfortable and safe temperature levels and strive to keep common resident areas between 71 and 81 degrees Fahrenheit.
Failure to Protect Resident from Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident #3 had severe cognitive impairment with diagnoses including Alzheimer's dementia, anxiety disorder, and depression, and was independent with mobility and walking. Resident #2 also had severe cognitive impairment with diagnoses including Alzheimer's dementia and anxiety disorder, was independent with mobility, and had a behavioral care plan noting physical and behavioral symptoms toward others, including hitting, pushing, and grabbing, with interventions to evaluate for signs of irritation and attempt redirection when upset with others. During an incident in the atrium, Resident #3 was uncomfortable with how close Resident #2 was standing, told Resident #2 to leave or move, and waved a hand in a swatting motion. Resident #2 then pushed Resident #3 with both hands against the abdomen, causing Resident #3 to fall backward onto the coccyx. After the fall, Resident #3 had pain in both wrists, swelling and bruising, became unresponsive, and was sent to the ER. The ER report documented a syncopal episode and inability to squeeze the physician's fingers, and wrist X-rays showed mildly displaced fractures of both distal radii and a fracture of the ulna styloid process. Staff interviews confirmed that one LPN witnessed the fall and that a CNA witnessed Resident #2 push Resident #3, and the DON stated staff were expected to redirect and follow care plans when residents act out.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify the resident's representative after a change of condition involving a coccyx wound for one resident with severe cognitive impairment, Alzheimer's dementia, diabetes mellitus, and urinary incontinence. The resident required staff assistance with bed mobility and personal cares, and a Braden assessment dated 7/30/25 showed severe risk for pressure ulcers. Nursing notes documented a small opening on the coccyx that was cleaned and covered with a 4x4 Mepilex, followed by continued monitoring of the wound and application of Calazime to the open area when it was noted to be tender and the resident reacted during assessment. The resident's coccyx wound was discussed with the resident's representative at the 7/30/25 care plan conference, but the medical record showed no evidence that the representative had been notified of the wound before that conference. The wound care nurse confirmed the representative was not notified prior to the care plan conference, and the resident's representative also confirmed she had not been notified before that meeting. The DON stated staff were expected to notify resident representatives anytime there is a change of condition outside their norm.
Failure to Protect Resident from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from physical abuse by another resident. Resident #3 had diagnoses including COPD, Parkinson's disease, and dementia, and a BIMS assessment could not be completed, indicating severe cognitive impairment. Resident #11 also had severe cognitive impairment for daily decision making and diagnoses including Alzheimer's disease, dementia with severe agitation, and anxiety. Resident #11 had a documented history of agitation and physical aggression toward others, including grabbing, hitting, kicking, and being physically aggressive, with interventions listed as redirection, one-to-one staff monitoring, reassurance, and ensuring resident safety. During the incident, resident #11 attempted to push resident #3's wheelchair. When resident #3 told him/her to stop, resident #11 hit resident #3 in the face multiple times with a closed fist and then grabbed resident #3's oxygen tubing and attempted to place it around resident #3's neck. Staff intervened before the tubing was placed around the neck. The residents were separated and assessed, with resident #3 showing redness to the cheek area and resident #11 showing red knuckles with a break in the skin. The facility investigation and staff interviews confirmed the resident-to-resident assault and the injury to resident #3.
Inadequate Nursing Staffing and CNA Coverage
Penalty
Summary
The facility failed to provide adequate nursing staff to meet resident needs and failed to maintain a licensed nurse in charge on each shift. The facility assessment dated 12/11/2025 showed an average census of short-stay and long-stay residents and listed staffing expectations of RN, LPN, and CNA/STNA hours per resident day for day and night shifts. The DON stated she staffed the schedule with 2 day shift nurses, 2 night shift nurses, and a minimum of 2 CNAs per station during the day and night shifts, then 1 CNA per station during the overnight 10 PM through 6 AM shift, and said she was unaware of the staffing hours needed from the facility assessment. Surveyors observed staffing shortages across multiple shifts and reviewed PBJ staffing data, worked schedules from 10/1/25 through 12/21/25, and Declaration of Nursing Staffing sheets. The PBJ Staffing Data Report for FY Quarter 1 2026 triggered excessively low weekend staffing. The worked schedules showed multiple periods when CNA staffing fell below the facility's stated staffing pattern, including shifts with only 1 CNA overnight and other shifts with 2 to 3 CNAs on duty. The Declaration of Nursing Staffing sheets for 5/25/26 through 5/31/26 also showed several shifts with only 1 to 3 CNAs on duty. Resident and staff interviews supported the staffing concerns. The resident council reported long call light times and delayed or missing food delivery due to low staffing. Resident #40 stated there was not enough staff and that having only 1 person covering any length of time was not enough. Resident #5 reported the facility was short on CNAs, call lights took a long time to answer, and clothing changes were delayed for 2 to 3 days. A CNA stated low staffing was an issue, staff called out frequently, and she felt overwhelmed.
Failure to Provide Written Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide a written notice of transfer/discharge before facility-initiated hospital transfers for 4 of 5 sampled residents (#6, #23, #30, and #31). Medical record review showed resident #6 was transferred to the hospital on 3/19/26, resident #23 on 2/10/26, resident #30 on 2/27/26, and resident #31 on 5/21/26 and 5/24/26, with no evidence that a written transfer/discharge notice had been issued to the resident and/or the resident representative for any of these transfers. During interview on 6/03/26 at 12:05 PM, the DON stated the Interact form was sent with residents when they were transferred to the hospital and that residents or their representatives were provided bed-hold information. The DON further confirmed that residents or their representatives were not provided with a written transfer/discharge notice. Review of the facility policy titled Transfer and Discharge, updated May 2025, stated that when transfer or discharge is initiated, the resident receives written notice using the Resident Notice of Transfer or Discharge, including the date notice is given, effective date, reason for the transfer/discharge, where the resident is to be moved, and contact information for the State Long-Term Care Ombudsman.
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Compliance trends in Wyoming
Data through May 2026Comparisons below measure the most recent period Jun 2025 – May 2026 against the prior period Jun 2024 – May 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
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