Citations in Wyoming
Comprehensive analysis of citations, statistics, 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 resident with moderately impaired cognition, dementia, depression, cancer, identified fall risk, and risk for skin breakdown was care planned to have the call light kept within reach, but surveyors observed the resident seated in a recliner with the call light out of reach on multiple occasions. The resident did not know where the call light was, had a wet brief, and could not request assistance, which was also confirmed by the resident’s representative, who noted the resident was covered with a blanket and not wearing pants underneath. A guest ultimately activated the call light, after which a CNA responded and removed soiled linens. The DON stated staff are expected to ensure residents have access to the call light and needed items when left alone, while the NHA acknowledged there was no facility policy on call light use.
A resident with hemiplegia, intact cognition, and need for assistance with toileting experienced physical and verbal abuse from a CNA during incontinence care. After the resident requested help, one CNA transferred the resident to a shower chair and a second CNA insisted on a shower despite the resident’s refusal, leading to an argument. The abusive CNA yelled, used profanity, made demeaning comments about the resident’s feces, scrubbed the resident and a wound roughly while the resident reported pain and asked her to stop, and allegedly positioned the shower chair to block access to the call light. Another CNA witnessed the yelling and rough care and heard the abusive statements. The CNA later admitted to using profanity and derogatory language. A nurse eventually entered and told the CNA to stop, ending the interaction. The DON acknowledged the incident as a concern and confirmed expectations that staff intervene and report abuse, while the facility’s abuse policy states that no abuse or harm will be tolerated.
Surveyors found that food safety standards were not followed when a dietary manager stored a personal cow hide in a black plastic bag on the floor of a warehouse walk-in freezer that also contained food for resident consumption. The hide was later observed to be frozen, with visible hair and ice accumulation, and was not stored at least 6 inches off the floor as required by the FDA Food Code. The administrator reported prior awareness of the hide’s presence and had previously instructed its removal, but was unsure if it had been removed and then returned, contrary to facility policy and food code requirements for preventing contamination.
The facility failed to submit mandatory direct care staffing data to CMS through the Payroll Based Journal (PBJ) system for three consecutive fiscal quarters while caring for 24 residents. PBJ staffing reports for fiscal year 2025 quarters 2, 3, and 4 each showed the facility triggered the metric “Failed to Submit Data for the Quarter.” In an interview, the DON acknowledged awareness that PBJ reporting was inconsistent and reported that the previous HR director had inconsistent access to the PBJ reporting system, which contributed to the lack of required staffing data submission.
A resident who had previously received PCV13 and consented to a pneumonia vaccine at admission did not receive the planned PCV20 dose, despite documentation that it was to be administered and a facility policy requiring assessment and provision of the pneumococcal vaccine series within 30 days of admission in accordance with CDC recommendations. Medical record review showed no documentation of vaccine administration, and the Infection Preventionist confirmed the vaccine was not given.
A resident with anxiety, insomnia, chronic pain, muscle weakness, and a history of CVA/TIA was ordered PRN Ativan 0.5 mg every six hours for anxiety without a documented stop date. A pharmacist’s monthly medication review recommended limiting non-antipsychotic psychotropic medications to 14 days, but the physician declined the recommendation and deferred to mental health, and no rationale for extended use or stop date was documented. The DON stated that staff were expected to follow up on monthly medication review orders kept in a binder, yet no further follow-up occurred, despite facility policy directing the prescriber and DON to act on recommendations from monthly regimen reviews.
A resident was involuntarily discharged without the facility providing a written discharge notice or completing discharge planning, as confirmed by review of progress notes and an interview with the DON. Facility policy required the Social Services Manager or designee to give written transfer or discharge notice to the veteran, the family or legal representative, and the State LTC Ombudsman, with 30 days’ notice for community-initiated transfers or discharges except in emergencies. These policy requirements were not followed in this case.
The facility failed to complete required PASRR screenings and evaluations for multiple residents with documented mental health diagnoses. One resident with moderate cognitive impairment, depression, and schizophrenia had no PASRR Level I or Level II documented in the record. Another resident with schizoaffective disorder had a PASRR Level I that concluded there was no evidence of mental illness, and although this resident consented to a PASRR Level II, no completed Level II was found in the record. A third resident with PTSD and schizophrenia had a PASRR Level I indicating evidence of mental illness and the need for a PASRR Level II, but no Level II was documented. The DON confirmed that PASRR Level II assessments should have been completed and reported that the staff member responsible had been locked out of the PASRR system, despite a facility policy requiring appropriate state determinations prior to admission for individuals with mental disorders or intellectual disabilities.
A deficiency occurred when a pharmacy’s monthly drug regimen review recommended discontinuation of hydroxyzine 25 mg PRN for anxiety for a resident, and the physician accepted this recommendation and ordered the medication discontinued, but the order was not carried out. Review of the physician orders showed the hydroxyzine remained active, and the DON confirmed it had not been discontinued. This was inconsistent with the facility’s “Interim Medication Regimen Review” policy, which requires the physician/prescriber to accept and act upon recommendations from the monthly medication review.
Surveyors found that in one cottage, an opened and partially used Insulin Glargine pen was stored without any indication of the date it was first used. An RN confirmed the pen had been used and acknowledged that insulin pens are required to be labeled with the opened date. The DON also confirmed that staff are expected to label multi-dose insulin with the date of opening. Review of facility policy showed all multi-dose vials must be dated and assigned a 28-day expiration at first use, and manufacturer instructions specified the pen should only be used for up to 28 days after first use, demonstrating that the undated insulin pen was not handled according to required procedures.
Failure to Ensure Call Light Accessibility and Supervision for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance devices to prevent accidents for one resident with moderately impaired cognition and multiple diagnoses, including non-Alzheimer’s dementia, depression, and cancer. The admission MDS showed a BIMS score of 12/15 and the care plan, last revised on 11/19/25, identified the resident as a moderate fall risk related to confusion, gait and balance problems, and psychoactive drug use, with an intervention initiated on 11/25/24 to ensure the call light was within reach. A Braden Scale assessment on 1/2/26 scored the resident at 16/23, indicating risk for skin breakdown. Despite these identified needs and care plan interventions, observations on 1/28/26 at 9:55 AM and 10:35 AM showed the resident seated in a recliner at the foot of the bed with the call light located at the head of the bed and not within reach, while the resident’s lower body was covered with a blanket. Further observations and interviews on 1/28/26 showed the resident did not know where the call light was and stated it “should be around here somewhere.” At 11:33 AM, the resident’s brief was confirmed to be wet, and the resident reported being unable to request assistance because the call light was not accessible. The resident’s representative also observed that the resident’s brief was wet, the resident was covered with a blanket without pants underneath, and the call light had not been within reach to request help. At 11:48 AM, the call light was activated by the resident’s guest, and at 11:53 AM a CNA answered the call light, closed the door, left the room, returned with a clean blanket, and exited at 12:04 PM with two bags of soiled linens. The DON later confirmed that staff are expected, when leaving a resident alone, to set the resident up with the call light and other needs and perform hand hygiene, and the NHA reported that the facility did not have a policy on call light use.
Failure to Protect Resident From Physical and Verbal Abuse During Personal Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from physical and verbal abuse by a CNA during personal care. The resident had hemiplegia/hemiparesis with upper and lower extremity impairment on one side and required partial/moderate assistance with toilet hygiene and transfers. During an episode of incontinence, the resident used the call light for help and was assisted by one CNA into a shower chair in the bathroom. A second CNA (CNA #1) then became involved in the care and insisted the resident take a shower, which the resident refused, leading to an escalating argument. According to the resident, CNA #1 yelled and cursed, scrubbed the resident very hard, was intentionally rough, and continued despite the resident’s reports of pain and requests to stop and get another caregiver. The resident reported that CNA #1 locked the shower chair brakes to prevent access to the call light and that the interaction caused pain during the incident and soreness afterward. Another CNA (CNA #2) reported hearing CNA #1 yelling and arguing with the resident, observed her scrubbing the resident and a wound while the resident said it hurt and asked her to stop, and heard CNA #1 refuse to stop. CNA #2 also reported hearing CNA #1 call the resident an “asshole” and state that the resident had “shit” in the genital area. CNA #1 acknowledged telling the resident they needed to get the “shit” off and admitted saying that if the resident was going to be an “ass,” she could be an “ass” too. CNA #1 described the resident yelling and kicking during care and stated she sprayed the resident with cold water accidentally, then began washing the resident and stopped when asked, but her account conflicted with the resident’s and CNA #2’s reports that she continued despite the resident’s objections. A nurse entered the room during the incident and told CNA #1 to stop talking to the resident, which ended the interaction. The DON later stated she considered the incident a concern and that staff who witness abuse are expected to intervene and report immediately, and it was noted that no formal plan of correction was implemented following this incident, despite the facility’s written abuse policy stating that no abuse or harm of any type will be tolerated and that veterans will be protected from abuse, neglect, and harm.
Improper Storage of Personal Cow Hide in Walk-In Freezer Used for Resident Food
Penalty
Summary
Surveyors observed that food was not stored in accordance with professional standards for food service safety in the facility’s warehouse walk-in freezer. During an observation, a black plastic bag was seen on the freezer floor near the entry door. The dietary manager stated the bag contained a cow hide that was his personal item and acknowledged that other items in the freezer were for resident consumption. Later observation showed the dietary manager opening the bag, revealing a frozen cow hide with black hair, folded and covered with ice on the flesh and hair. The hide was stored directly on the freezer floor, not elevated as required. The facility administrator reported he had been aware of the cow hide being stored in the freezer months earlier and had instructed the dietary manager to remove it, believing it had been taken out. He was unsure whether the hide had been removed and then returned to the freezer. Facility policy on food preparation and storage required protection of food from contamination or cross-contamination in accordance with the current food code, including proper storage and handling. The 2022 FDA Food Code requires food to be stored in a clean, dry location, protected from contamination, and at least 6 inches above the floor, which was not followed in this instance.
Failure to Submit Required Payroll Based Journal Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS through the Payroll Based Journal (PBJ) system as required. Review of the PBJ staffing reports for fiscal year 2025 quarter 2 (January 1–March 31), quarter 3 (April 1–June 30), and quarter 4 (July 1–September 30) showed the facility triggered the metric “Failed to Submit Data for the Quarter” for each of these three consecutive quarters, during which the census was 24. In an interview, the DON stated the facility was aware that PBJ reporting was not consistent and further explained that the previous HR director had inconsistent access to the PBJ reporting system, contributing to the failure to submit the mandatory staffing data.
Failure to Administer Indicated Pneumococcal Vaccination After Consent and Policy Requirements
Penalty
Summary
The facility failed to ensure a resident was immunized for pneumococcal disease in accordance with its own policies and current CDC recommendations. Medical record review showed the resident’s most recent Pneumococcal Conjugate Vaccine (PCV13) was administered on 10/18/19, and the facility documented a plan to administer Prevnar 20 at the time of admission in July 2025, but there was no record that this vaccine was actually given. A vaccine consent form dated 7/9/25 showed the resident had consented to receive the pneumonia vaccine. In an interview on 1/23/26 at 10:00 AM, the Infection Preventionist confirmed the resident did not receive the planned vaccine. The facility’s written policy, dated 12/2023, required that veterans be assessed for eligibility for the pneumococcal vaccine series prior to or upon admission and, when indicated, be offered the vaccine series within 30 days of admission, with administration to follow current CDC recommendations. CDC guidance in effect at the time stated that adults over a specified age who previously received one dose of PCV13 should receive one dose of PCV20 or PCV21 at least one year after the last PCV13 dose, which had not occurred for this resident.
Failure to Limit PRN Psychotropic Medication to 14 Days and Act on Pharmacist Review
Penalty
Summary
Surveyors identified a failure to limit an as-needed psychotropic medication to 14 days for one resident. The resident had a BIMS score of 15/15, indicating intact cognition, and diagnoses including anxiety disorder, insomnia, chronic pain, muscle weakness, and a history of cerebrovascular accident or transient ischemic attack. Physician orders dated 12/8/25 showed the resident was receiving Ativan 0.5 mg every six hours as needed for anxiety without any documented stop date. A monthly medication review dated 12/29/25 documented that the pharmacist recommended limiting non-antipsychotic psychotropic medications to 14 days, but the physician declined this recommendation and deferred the issue to mental health, and the medical record contained no physician rationale for extended use or a stop date. The DON reported that staff were expected to follow up on monthly medication review orders placed in a binder at the nursing station, but there was no additional follow-up on the pharmacist’s recommendation by nursing or mental health services, despite facility policy stating that the physician/prescriber and DON should act upon recommendations in the monthly regimen reviews. This resulted in the continued use of an as-needed psychotropic medication without adherence to the 14-day limitation or documented justification for extended use, contrary to the facility’s medication regimen review policy.
Failure to Provide Required Written Notice and Discharge Planning for Involuntary Discharge
Penalty
Summary
The facility failed to provide required written discharge notice and conduct discharge planning for a resident who was involuntarily discharged. Medical record review showed a progress note dated 10/28/25 at 1:05 PM documenting that resident #24 was involuntarily discharged from the facility, but further review of the progress notes revealed no evidence that a written discharge notice was given to the resident or the resident’s representative, nor that discharge planning was completed prior to the discharge. In an interview on 1/22/26 at 4:26 PM, the DON confirmed that no written discharge notice was issued and no discharge planning was performed before the resident left the facility. Review of the facility’s policy titled “Transfer or discharge,” dated 12/4/23, showed that the WVSN Social Services Manager, or designee, is responsible for providing the veteran and family member or legal representative, and the Office of the State Long-Term Care Ombudsman, with a notice of transfer or discharge, and that notice of community-initiated transfer or discharge is to be provided 30 days before transfer or discharge unless there is an emergency transfer. The documentation and interview findings demonstrated that these policy requirements were not followed for this involuntary discharge.
Failure to Complete Required PASRR Level I and Level II Evaluations for Residents With Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to ensure required Preadmission Screening and Resident Review (PASRR) Level I and Level II evaluations were completed for residents with mental disorders or intellectual disabilities. One resident with moderate cognitive impairment and diagnoses including depression and schizophrenia had no evidence in the medical record that any PASRR screening was completed prior to or following admission in July 2025, which was confirmed by the DON. For a second resident with a diagnosis of schizoaffective disorder, the PASRR Level I dated 9/18/25 documented responses of “no” to questions regarding major mental illness, history of mental illness requiring more than outpatient treatment in the past two years, and current evidence of mental illness, and the Level I summary concluded there was no evidence of mental illness or intellectual disability, despite the documented schizoaffective disorder diagnosis. A third resident had a PASRR Level I dated 11/6/25 showing diagnoses including PTSD and schizophrenia, and the Level I summary indicated there was evidence of mental illness and that a PASRR Level II was required. For both the second and third residents, the medical records contained no evidence that the required PASRR Level II assessments were completed, even though one resident had signed a PASRR Level II informed consent form dated 10/14/25. In an interview, the DON confirmed that PASRR Level II assessments should have been completed for these two residents and stated that the staff member responsible for completing the assessments had been locked out of the PASRR system. The facility’s PASARR policy stated that the community would not admit new veterans with mental disorder or intellectual disability unless the appropriate state authority had made the required determinations prior to admission, but the documented screenings and missing Level II assessments did not align with these requirements.
Failure to Discontinue Medication After Accepted Pharmacy Recommendation
Penalty
Summary
The deficiency involves the facility’s failure to act on a pharmacy recommendation and corresponding physician order to discontinue an unnecessary medication for one resident. A monthly medication regimen review for December 2025 documented that the consulting pharmacy recommended discontinuing hydroxyzine 25 mg, ordered as needed for anxiety. The medical record showed that the physician accepted this recommendation and ordered the hydroxyzine to be discontinued. However, review of the physician orders revealed that the hydroxyzine order remained active and had not been discontinued. In an interview on 1/23/26 at 8:30 AM, the DON confirmed that the medication had not been discontinued. Review of the facility’s policy, “Interim Medication Regimen Review” (last updated 2018), showed that the physician/prescriber should accept and act upon recommendations contained within the monthly medication review, which did not occur in this case. This failure to implement the accepted pharmacy recommendation and physician order for discontinuation of hydroxyzine for anxiety constituted noncompliance with the facility’s own policy and procedures for monthly drug regimen review and unnecessary medications.
Failure to Date Opened Insulin Pen per Policy and Manufacturer Instructions
Penalty
Summary
Surveyors identified a deficiency in medication labeling and dating practices when, during observation in the Cottonwood cottage, an opened and partially used Insulin Glargine 100 unit/mL pen was found without a date indicating when it had been first used. At the time of observation, an RN confirmed that the insulin pen had been used and acknowledged that insulin pens were expected to be labeled with the date they were opened. The DON later confirmed that staff were expected to label multi-dose insulin with the date of opening. Review of the facility’s policy titled “Multidose Vial Use” dated August 2024 showed that all multi-dose vials must be dated with a 28‑day expiration date and labeled with the expiration date at the time of original opening by the person initially accessing the vial. Additionally, review of the insulin manufacturer’s prescribing information, last revised in 2025, indicated that the pen should only be used for up to 28 days after first use, further underscoring that the undated, opened insulin pen was not in compliance with established labeling requirements. No specific resident, medical history, or clinical condition was described in relation to the use of this insulin pen; the deficiency centered on the facility’s failure to label a multi-dose insulin pen with the date it was opened, contrary to facility policy and manufacturer instructions.
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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