Wyoming Veterans' Skilled Nursing Facility

In the surveyor’s words

From the most serious findings on record at Wyoming Veterans' Skilled Nursing Facility, in the surveyor’s own words.

• Actual harm, isolatedF600Jan 23, 2026

  Based on medical record review, incident review, staff interview, and policy and procedure review, the facility failed to protect the residents' right to be free from physical and verbal abuse by a staff member for 1 of 2 sample residents (#3) reviewed for allegations of abuse. This failure resulted in actual harm to resident #3. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #3 had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included hemiplegia or hemiparesis, anxiety disorder, chronic inflammatory skin condition, and restless leg syndrome. […]

• No harm, potential for more than minimal, widespreadF812Jan 23, 2026

  Based on observation, staff interview, policy and procedure review, and food code review, the facility failed to ensure food was stored in accordance with professional standards for food service safety. The census was 24. The findings were: 1. Observation of the warehouse walk-in freezer on 1/22/26 at 10:12 AM showed a black plastic bag was positioned near the entry door, on the floor. Interview with the dietary manager at that time, revealed the bag contained a cow hide, which was his personal item, and he was planning to remove it that day. The manager stated the hide had not been in the freezer long and he confirmed the other items in the freezer were for resident consumption. […]

• No harm, potential for more than minimal, widespreadF851Jan 23, 2026

  Based on payroll based journal staffing report review, and staff interview, the facility failed to ensure mandatory submission of staffing data. The census was 24. The findings were:1. Review of the fiscal year 2025 quarter 2 (January 1-March 31) payroll based journal staffing report showed the facility triggered for the metric Failed to Submit Data for the Quarter.2. Review of the fiscal year 2025 quarter 3 (April 1-June 30) payroll based journal staffing report showed the facility triggered for the metric Failed to Submit Data for the Quarter.3. Review of the fiscal year 2025 quarter 4 (July 1-September 30) payroll based journal staffing report showed the facility triggered for the metric Failed to Submit Data for the Quarter.4. […]

• No harm, potential for more than minimal, isolatedF605Jan 23, 2026

  Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure as needed psychotropic medications were limited to 14 days for 1 of 6 sample residents (#6) reviewed for unnecessary medications. 1. Review of the quarterly MDS assessment dated [DATE] showed resident #6 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included anxiety disorder, insomnia, chronic pain, muscle weakness, and a history of cerebrovascular accident or transient ischemic attack. The following concerns were identified:a. Review of the physician orders dated 12/8/25 showed the resident received Ativan 0.5 milligrams (mg) every six hours as needed for anxiety. There was no evidence a stop date was indicated.b. […]

• No harm, potential for more than minimal, isolatedF628Jan 23, 2026

  Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure written discharge notice was provided to residents or resident representatives for 1 of 2 sample residents (#24) reviewed for closed records. The findings were: 1. Review of a progress note dated 10/28/25 and 1:05 PM showed resident #24 was involuntarily discharged from the facility. Further review of the progress notes showed no evidence the facility provided a written discharge notice or completed discharge planning prior to the resident's discharge.2. Interview with the DON on 1/22/26 at 4:26 PM confirmed the facility did not issue a written discharge notice or perform discharge planning prior to the resident's discharge.3. […]