CMS · Wyoming Healthcare Licensing and Surveys publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-30Record 53A051-20260106-F609
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-30Record 53A051-20260106-F610
F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-31Record 53A051-20250710-F578
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-08-15Record 53A051-20250710-F600
F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-08-19Record 53A051-20250710-F605
F679Provide activities to meet all resident's needs.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-08-15Record 53A051-20250710-F679
F680Ensure the activities program is directed by a qualified professional.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-08-19Record 53A051-20250710-F680
F837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-12-08Record 53A051-20250710-F837
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-08-22Record 53A051-20250710-F880
F576Ensure residents have reasonable access to and privacy in their use of communication methods.Scope/severity CPaperwork
Dignity & rights
Widespread; potential for minimal harm.Corrected 2025-08-18Record 53A051-20250710-F576
F729Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2025-08-15Record 53A051-20250710-F729
F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-18Record 53A051-20240328-F578
F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-15Record 53A051-20240328-F584
F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-06Record 53A051-20240328-F688
F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-25Record 53A051-20240328-F758
F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-05-18Record 53A051-20240328-F801
F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-04-22Record 53A051-20240328-F803
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-05-18Record 53A051-20240328-F812
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-06Record 53A051-20240328-F880
F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-01Record 53A051-20230126-F688
F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-01Record 53A051-20230126-F758
F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Scope/severity BPaperwork
Dignity & rights
Pattern; potential for minimal harm.Corrected 2023-03-01Record 53A051-20230126-F568
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity BPaperwork
Care planningRecords
Pattern; potential for minimal harm.Corrected 2023-03-01Record 53A051-20230126-F656
F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2023-03-01Record 53A051-20230126-F727