Based on review of personnel records, staff interview, and medical record review, the facility failed to ensure the director of nursing was licensed by the State of Wyoming before providing nursing care to facility residents for 5 of 13 (#1, #2, #3, #4, #5) residents reviewed. The facility census was 74. The findings were: 1. Review of the former DON's personnel record showed she was hired on 3/11/24. There was no evidence the former DON had a valid Wyoming nursing license upon hire. The following concerns were identified: a. Review of the medical record for resident #1 showed an Abnormal Involuntary Movement Scale (AIMS) assessment was completed by the former DON on 3/19/24. b. …
F839 citations in Wyoming
Administration Deficiencies
Employ staff that are licensed, certified, or registered in accordance with state laws.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2024
Wyoming cites F839 more often than its own record predicts
7.84 times the share F839 takes of citations nationally.
Of every deficiency written in Wyoming in 2024, this is the portion that was F839.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Wyoming surveyors wrote
F839 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.
What else Wyoming surveyors cite →
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