Based on review of the Facility Assessment and staff interview, the facility failed to consider specific staffing needs for each shift, such as day, evening, night, and adjust as necessary based on any changes to its resident population. The census was 69. The findings were: Review of the Facility Assessment 2026 dated 1/5/26 showed the total of full-time employees; however, the assessment failed to include the evaluation of resident acuity and specific staffing needs for each shift for RNs, LPNs, MA-Cs, and CNAs to meet the needs of the residents who resided within the facility. Interview with the administrator on 4/22/26 at 3:40 PM confirmed he did not include the specific staffing needs. Further interview revealed he believed he had completed the facility assessment per requirements.
F838 citations in Wyoming
Facility assessment · Administration Deficiencies
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
No F838 citations were recorded in Wyoming for 2025. That means none appear in the CMS file for that year — not that the requirement does not apply.
In the surveyor’s words
What Wyoming surveyors wrote
F838 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 review of the facility assessment, staff interview, and policy and procedure review the facility failed to review and update the facility assessment at least annually for 1 of 1 facilities. The census was 112. The findings were: 1. Review of the facility assessment showed the facility last completed a facility assessment in October 2021. Further review showed no evidence a facility assessment review and update was completed from October 2021 to March 2023. 2. Interview with the ADON on 3/7/23 at 1:20 PM revealed the most recent facility assessment was completed on October 2021 and she confirmed a facility assessment had not been completed for 2022. 3. …
What else Wyoming surveyors cite →
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