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
A facility failed to keep residents’ personal and medical records secure and confidential. Medical record review showed hospice notes were entered directly into the EMR for three residents, and the regional clinical director stated the hospice previously used was given full access to the EMR for all residents. The Resident Rights policy stated residents have a right to secure and confidential personal and medical records.
Failure to Offer Choice of Hospice Provider: The facility did not ensure that 3 residents receiving hospice services were offered a choice of hospice provider. Medical record review showed no evidence that the residents were given provider choice, and an RCD confirmed that prior to the operator transition, hospice residents were not given a choice. The facility's Resident Rights policy states residents have the right to choose health care and providers of health care services.
Failure to Assess and Document Changes in Condition: A resident with repeated falls, hypoxia, lethargy, and later hospital transfers had multiple episodes where assessments, vital signs, or follow-up documentation were missing or delayed. Another resident with COPD and impaired gas exchange was observed in respiratory distress without oxygen and was later transferred for respiratory failure, with no transfer documentation on the progress notes. A third resident with dementia and a history of falls had incomplete post-fall assessments and was later sent to the hospital after additional falls and pain. A fourth resident with a Foley catheter had cloudy, low, and absent output, pain, and family requests for transfer; the catheter was later found to have caused traumatic injury and hematuria.
Opened medications in two medication fridges were found without required opened-on or discard dates. An Ozempic pen in one fridge and an opened Tubersol vial plus an opened Ativan oral solution in another fridge were all in use but unlabeled, and staff confirmed the missing dates. The DON stated she expected in-use multi-dose vials to have an opened-on or discard-by date, and manufacturer guidance reviewed for these medications specified discard timelines after opening.
A facility failed to ensure hospice services met professional standards for 3 sampled residents. Medical record review showed each resident was receiving hospice services, but none of the records contained a physician order for hospice referral or eval. An RCD confirmed that residents placed on hospice did not receive a physician order for eval and that the hospice used at the time had access to all resident medical records.
Infection control was not maintained during meal service and resident care. A CNA touched hair, clothing, and other surfaces while handling meal tickets, food, and drink cups without hand hygiene, including placing chips on a resident’s burger and touching cup rims. Staff also left visibly soiled linens in place for a resident with bowel incontinence, and oxygen cannulas/tubing for multiple residents were found on the floor or unlabeled, with one cannula picked up from the floor and placed on a resident.
Failure to Protect Confidential Medical Records
Penalty
Summary
The facility failed to ensure residents’ personal and medical records remained secure and confidential. Medical record review showed that resident #26 received hospice services beginning on 1/2/26, resident #83 received hospice services beginning on 1/21/26, and resident #84 received hospice services beginning on 2/5/26, and the hospice provided documented notes directly into the electronic medical record system. During interview on 5/6/26 at 12:44 PM, the regional clinical director stated the only hospice used prior to a change in operator was given full access to the electronic medical record for all residents. Review of the facility’s Resident Rights policy stated residents have a right to privacy and confidentiality of personal and medical records and the right to secure and confidential records.
Failure to Offer Choice of Hospice Provider
Penalty
Summary
The facility failed to ensure residents' right to choose their health care providers for 3 of 12 sampled residents reviewed for hospice services. Resident #26 began receiving hospice services on 1/2/26, resident #83 began receiving hospice services on 1/21/26, and resident #84 began receiving hospice services on 2/5/26, but the medical record review showed no evidence that any of these residents were offered a choice in hospice provider. During an interview on 5/6/26 at 12:44 PM, the regional clinical director confirmed that prior to the operator transition, residents on hospice were not given a choice for hospice provider. The facility's Resident Rights policy, last revised on 6/10/25, states that the resident has the right to choose health care and providers of health care services consistent with his or her interests, assessments, and plan of care.
Failure to Assess and Document Changes in Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for four residents who experienced changes in condition. For resident #1, the record showed multiple episodes where the resident was found after falls, had low oxygen saturations, became lethargic, or was unresponsive, yet there was no evidence of timely assessments, vital signs, or follow-up documentation at several of those events. The record also showed a late entry note for a 3/5/26 incident was added 62 days after the event. The resident was later transferred to the hospital for respiratory failure, pneumonia, acute heart failure, dry gangrene, hyponatremia, metabolic encephalopathy, pulmonary edema, critical electrolyte abnormalities, atrial fibrillation with RVR, and acute kidney injury. For resident #69, the resident had diagnoses including chronic myeloid leukemia, CAD, seizure disorder, traumatic brain injury, and COPD, and the care plan addressed impaired gas exchange. On 5/4/26, the resident was observed sitting on the edge of the bed with a respiratory rate of 30-40 breaths per minute, grey pallor, and no oxygen in place. The resident was later sent to the hospital for respiratory failure, but the progress notes for the transfer did not show documentation on 5/5/26. A later facility note stated the resident had been found with oxygen saturation of 60% on 4 lpm NC, difficulty breathing, and lethargy, and the LPN reported she had been asked to come in on her day off to document the assessment and transfer. For resident #81, who had severe cognitive impairment, dementia, COPD, atrial fibrillation, CAD, diabetes, and a history of falls, the record showed repeated falls and incomplete assessments. After a fall on 4/20/26, the assessment section was left blank. Another note dated 4/23/26 documented pain, confusion, and unsteadiness but stated there were no safety risks. After a fall on 4/25/26, staff documented vital signs and a normal assessment but did not know whether the resident hit his/her head, and there was no evidence of follow-up assessments. After a fall on 4/30/26, the resident was found on the floor with pain, and the interdisciplinary review identified impaired cognition, weakness, and self-transfers as the root cause, with a new skin tear noted. The resident's representative reported the resident was in significant pain, not at baseline, disheveled, saturated with urine, had neck swelling, and was missing a pain patch, and stated no vital signs or assessment had been done before the resident was sent to the hospital. For resident #6, who had moderate cognitive impairment, cancer, CAD, heart failure, renal disease, dementia, and an indwelling catheter, the care plan identified UTI risk related to the Foley catheter. After a recent hospitalization for sepsis related to UTI/prostate cancer, the record showed thick cloudy catheter output, complaints of pain, and periods of no catheter output. The resident's family repeatedly requested hospital transfer, and the catheter was changed after the resident had no output since the prior shift; the catheter then drained but had bloody urine. The resident later had cloudy grayish-yellow urine, was not getting up for breakfast, and was transferred to the ED. The ER report stated the Foley had caused traumatic injury and hematuria because the balloon was inflated in the prostatic urethra, and the resident also had AKI with creatinine elevated above baseline. The DON stated she expected transfer documentation to include resident condition, vital signs, notifications, and immediate or within-24-hour documentation, and confirmed that only vital signs were completed and ongoing assessment was not completed as expected.
Medication Labeling Deficiency in Two Medication Fridges
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with accepted professional principles because opened medications in two medication refrigerators did not have an opened-on or discard date. During observation in the Rock Creek medication fridge, an Ozempic 8 mg/3 ml pen was found with no opened-on or discard date. MA-C #1 confirmed the Ozempic pen had been opened and used the day before and that no date had been written on it. In the secure unit fridge, an opened Tubersol vial and an opened Ativan oral solution 2 mg/ml were observed without opened-on or discard dates. LPN #2 confirmed both medications were in use and that neither had the required dates. The DON stated she expected an opened-on or discard-by date to be written on in-use multi-dose vials. Manufacturer instructions reviewed for Ozempic, oral liquid Lorazepam, and Tubersol specified time limits for use after opening, and the facility policy required multi-use vials to include the date initially opened or accessed.
Missing Physician Orders for Hospice Referrals
Penalty
Summary
The facility failed to ensure hospice services met professional standards for 3 of 12 sampled residents. Medical record review showed that resident #7 began receiving hospice services on 3/31/26, resident #83 began receiving hospice services on 1/21/26, and resident #84 began receiving hospice services on 2/5/26, but none of the three records contained evidence of a physician order for a hospice referral or evaluation. During interview on 5/6/26 at 12:44 PM, the regional clinical director confirmed that residents placed on hospice did not receive a physician order for evaluation and that the hospice used at that time was given access to the medical record for all residents.
Infection Control Lapses During Dining, Linen Care, and Oxygen Equipment Handling
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained for resident care and meal service. During dining room observation, a CNA touched his hair, handled resident meal tickets, and repeatedly handled resident food and drink items with exposed hands without performing hand hygiene between tasks. The CNA placed a bag of chips on top of a resident’s hamburger, touched the top bun to apply jelly, handled drink cups by the rims, and continued passing trays after touching his pants, hair, and other surfaces. The infection preventionist and DON confirmed staff were expected to perform hand hygiene after touching hair, skin, or clothing and that the CNA should not have touched resident meal items without hand hygiene. The facility also failed to manage soiled linens and oxygen equipment for residents with visible contamination or tubing on the floor. One resident had linens visibly soiled with bowel movement incontinence, yet the blanket was pulled over the sheets, the soiled linen remained visible during later observations, the resident lay on top of an oxygen cannula on the soiled sheets, and housekeeping picked up the cannula from the floor and placed it on the resident. Two other residents had nasal cannulas or oxygen tubing on the floor or unlabeled, including tubing dated 4/19/26 and tubing labeled 5/3/26 that remained on the floor during repeated observations. The IP confirmed oxygen tubing should be changed and labeled weekly and as needed or when visibly soiled, that cannulas found on the floor should not be used on residents, and that soiled linens should be changed immediately.
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Compliance trends in Wyoming
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 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: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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 May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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).
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Some of the Latest Corrective Actions taken by Facilities in Wyoming
- CNA #2 was suspended pending an investigation, an abuse allegation investigation was initiated, including resident interviews and reporting to appropriate entities, and education was provided to all staff on abuse reporting and investigation procedures. (K - F0610 - WY)
- Resident assessment was conducted, the involved CNA was suspended, the facility reported the incidents to the adult protection agency, state survey agency, and state board of nursing, and disciplinary action was taken against the perpetrators. (G - F0600 - WY)
- The facility implemented a Quality Assessment and Performance Improvement (QAPI) program addressing resident-to-resident abuse, placed the aggressive resident on increased and then one-to-one observation, provided staff training on behavior management and working with residents exhibiting aggression, and made plans to transfer the aggressive resident to another facility. (G - F0600 - WY)
Failure to Investigate Abuse Allegation and Protect Resident
Penalty
Summary
The facility failed to respond to an allegation of abuse and protect a resident's right to be free from verbal abuse by a staff member. The incident involved a CNA who verbally abused a resident and attempted to physically move the resident against their will. The grievance was reported by another CNA and witnessed by an LPN, but the facility did not take immediate action to investigate or protect the resident. The abusive CNA continued to work multiple shifts following the incident, and the grievance was not logged in the facility's grievance log. Interviews with staff revealed that the incident was reported to the Business Office Manager (BOM), who asked the reporting CNA to document it in writing. Despite this, the grievance was not acted upon promptly, and the abusive CNA remained on duty. The facility's failure to investigate the abuse allegation and protect the resident led to a determination of immediate jeopardy. The facility's policy required immediate reporting and investigation of abuse allegations, which was not followed in this case.
Removal Plan
- CNA #2 was suspended pending an investigation.
- An abuse allegation investigation was started which included resident interviews and reporting of the allegation to the appropriate entities.
- Education was provided to all staff on abuse reporting notification and investigation which included education of oncoming staff before contact with residents.
Failure to Provide CPR According to Advance Directive
Penalty
Summary
The facility failed to provide CPR in accordance with a resident's advance directive, resulting in the resident's death shortly after admission. The resident had signed a POLST indicating a full code status, which was also signed by the physician. However, when the resident became unresponsive and lost signs of life, the staff did not initiate CPR. The administrator and the DON both believed the resident was a DNR/DNI based on information from the hospital and were unaware of the updated POLST. The POLST was not found in the disaster recovery binder at the nurses' station, and there was no documentation of the resident's mottling or physician notification prior to the resident's death. Interviews with various staff members revealed a lack of awareness and communication regarding the resident's code status. The LPN who admitted the resident did not recall the resident's code status, and the social worker confirmed that medical records personnel processed the admission paperwork, including the POLST. The physician who signed the POLST was not notified of any concerns until the resident's death. The facility's policies on code blue and advance directives were not followed, leading to the failure to provide CPR as requested by the resident's advance directive.
Removal Plan
- Education to all staff regarding POLST forms and code blue.
- 100% audit of all POLST forms for all current residents.
- Audit of all licensed nurses for verification of up to date CPR.
- A mock Code Blue drill was conducted and would occur on every shift.
Resident Abuse and Neglect by CNAs
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse, as well as neglect, as evidenced by incidents involving two CNAs. The resident, who had severe cognitive impairment and was dependent on staff for personal care, was left unattended in the bathroom and went unchecked for 13 hours during a CNA's shift. This neglect was captured on audio/video surveillance, and other staff reported concerns about the conditions of residents, such as saturated briefs and beds, and dried feces and urine left on beds. In another incident, the resident's daughter provided video footage showing a CNA verbally and physically abusing the resident. The footage showed the CNA pushing the resident in bed, pulling the resident up by one arm, and using aggressive and threatening body language. The CNA was also observed turning off the resident's call light and refusing to take the resident to the bathroom, leading to the resident expressing fear about calling for help. Interviews revealed that the CNA involved in the physical and verbal abuse had complained about being overwhelmed and needing help. The CNA stated that she had no intention of hurting the resident and was frustrated during the shift. The resident's daughter reported these incidents to the facility, and the resident exhibited new fearful behavior following the incidents.
Removal Plan
- Resident assessment
- CNA suspension
- Facility reported to adult protection agency, state survey agency, and state board of nursing
- Disciplinary action for the perpetrators
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, resulting in harm to two residents. Resident #5, who had moderate cognitive impairment and various medical conditions, was injured in an altercation with resident #1, who also had significant cognitive impairment and other health issues. During the incident, resident #1 entered resident #5's room, became agitated, and pushed resident #5, causing them to fall and sustain a fracture. This incident was documented in an incident report and confirmed through a facility investigation. A subsequent incident involved resident #1 entering the room of resident #2, who had significant cognitive impairment and multiple diagnoses. Resident #1 hit resident #2 on the shoulder, causing slight redness. This altercation occurred during a shift change when resident #1 was unsupervised, despite being on 1:1 observation. The facility's investigation substantiated both incidents, indicating a failure to adequately supervise and protect residents from abuse.
Removal Plan
- Implemented a quality assessment process improvement (QAPI) program addressing resident-to-resident abuse.
- Placed resident #1 on increased observation.
- Provided staff training including behavior management and working with residents with behaviors to decrease the risk of aggression towards other residents.
- Placed resident #1 on 1:1 observation.
- Plans made to transfer resident #1 to another facility.
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