Based on observations, record reviews, and interviews, the facility failed to make prompt efforts to resolve resident grievances for 1 of 21 residents reviewed for abuse. The facility failed to make prompt efforts to resolve a grievance Resident #16 filed regarding verbal abuse from Housekeeper A.Housekeeper A confronted and yelled at Resident 16 after the resident filed grievances about Housekeeper A. Housekeeper A returned to Resident #16's door the following day and intimidated Resident #16 by belittling and laughing at her to CNA J and CMA K knowing Resident #16 was looking at her and could hear Housekeeper A as she spoke. The facility failed to initiate an investigation or report to a State Agency allegations of abuse invovling Resident #16 from Housekeeper A. …
F166
Resident Rights Deficiencies
Try to resolve each resident's complaints quickly.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
The harm level
How severely F166 is cited
0.0% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D2100.0% | E— | F— |
| No harm, potential for minimal | A— | B— | C— |
In the surveyor’s words
What an F166 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on record review and interviews the facility failed for 2 (#1, and #4) of 28 sampled Residents to ensure that grievances were thoroughly investigated according to facility policy, and failed to ensure efforts were promptly made to effectively resolve concerns identified for all residents. Findings include: The facility's Grievance Guideline indicated all employees are responsible for ensuring customer satisfaction. The Facility's Grievance Guidelines indicated that when concerns arise, a grievance system is in place to resolve the issues to the satisfaction of all parties involved. …
Based on interview and record review, the facility failed to make prompt efforts to resolve a grievance for one of three sampled residents (Resident 1) when Resident 1 reported that facility staff were in possession of his keys after his discharge. There was no documentation the facility addressed Resident 1's complaint. This failure resulted in anger and frustration for Resident 1 and caused a delay in the return of his personal property. Findings: The record for Resident 1 was reviewed. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. …
Based on observation, review of policy and procedure, and staff interview, the facility failed to ensure a grievance posting with the required information. The census was 170. The findings were: Review of the Grievance/Concern policy last revised 11/2016 showed there was to be a posting which contained information related to the right to file grievances orally or in writing, the right to file grievances anonymously, the contact information of the grievance official, the expected time frame for completing a review of grievances, the resident's right to receive a written decision regarding concern/grievance, and contact information of independent entities with whom grievances may be filed, that is, the pertinent State Agency; Quality Improvement Organization; State Survey Agency and State… …
Shepherd of the Valley Rehabilitation and Wellness · Wyoming
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