Based on observation, medical record review, staff interview, closed-circuit camera review, and policy and procedure review, the facility failed to protect the resident's right to be free from neglect for 1 of 3 sample residents (#6) reviewed for abuse and neglect. This failure resulted in the death of resident #6 who exited the facility without being noticed and was outside in winter weather conditions for 9 hours and 17 minutes. This failure resulted in the determination of immediate jeopardy due to the lack of necessary services to ensure residents' safety. On [DATE] there were 19 residents on the Cottonwood and Pine units who were identified as high-risk for wandering/elopement. Corrective measures were implemented prior to the survey and compliance was determined to be met on [DATE]. …
F600 citations in Wyoming
Abuse and neglect · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Wyoming cites F600 more often than its own record predicts
3.63 times the share F600 takes of citations nationally.
Of every deficiency written in Wyoming in 2025, this is the portion that was F600.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Wyoming surveyors wrote
F600 findings written in Wyoming, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on medical record review, resident representative and staff interview, facility incident report review, plan of correction review, and policy and procedure review, the facility failed to protect the resident's right to be free from sexual abuse by a resident for 1 of 4 sample residents (#3) reviewed for abuse. This failure resulted in actual harm to resident #3. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #3 had severely impaired cognitive function and diagnoses which included cerebral palsy, anxiety disorder, anoxic brain damage, and unspecified disorder of adult personality and behavior. Further review showed the resident was non-verbal, non-ambulatory, impaired in both lower extremities, and wheelchair bound. …
Based on observation, medical record review, facility incident report review, facility investigation review, staff interview, resident grievance review, and policy review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 5 sample residents (#6) reviewed for abuse. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #6 had a BIMS score of 6 out 15, which indicated severe cognitive impairment, and diagnoses which included non-Alzheimer's dementia. The review showed the resident was independent with transfers and was able to walk 150 feet with supervision or touching assistance. …
The short window
Recent years
| Year | Share of Wyoming citations | vs expected |
|---|---|---|
| 2023 | 8.67% | 4.89× |
| 2024 | 7.11% | 3.02× |
| 2025 | 9.50% | 3.63× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wyoming surveyors cite →
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