Cycle 1
Health 2025-08-07 · Fire 2025-08-07
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Rawlins, WY
dba/Rawlins Rehabilitation and Wellness
3-star overall rating with 3-star inspections with $14,433 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
542 16th St, Rawlins, WY
(307) 324-2759
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
62
Certified beds
Average residents
34
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Evergreen Healthcare Group
Operator or chain grouping
Approved since
1989-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
41 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.03
Registered nurse staffing · state 0.90 · national 0.68
LPN hours / resident day
0.37
Licensed practical nurse staffing · state 0.48 · national 0.87
Aide hours / resident day
2.34
Nurse aide staffing · state 2.46 · national 2.35
Total nurse hours
3.74
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.30 · national 3.43
Weekend RN hours
0.94
Weekend registered nurse coverage · state 0.62 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.06
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 53% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,458
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.60
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.35
Baseline 56.82% · Performance 54.05% · Measure score 2.35 · Achievement 2.35 · Improvement 0.36
Adjusted total nurse staffing
2.36
Baseline 3.85 hours · Performance 3.75 hours · Measure score 2.36 · Achievement 2.36 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 25 · Denominator 25 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 25 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 25 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 13.56% |
8.2%
5.4 pts better
|
Numerator 8 · Denominator 59 |
| Staff flu vaccination coverage | 94.44% |
42%
52.4 pts better
|
Numerator 68 · Denominator 72 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.3
0.5 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 1.0 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.2
0.9 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.5 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
94.3%
0.7 pts better
|
93.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 82.4% · Q2 97.4% · Q3 100.0% · Q4 100.0% · 4Q avg 95.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.3%
5.7 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
4.8%
1.9 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.1% · Q3 0.0% · Q4 0.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 23.6% |
6.4%
17.2 pts worse
|
11.4%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 25.0% · Q3 16.7% · Q4 25.0% · 4Q avg 23.6% |
| Percentage of long-stay residents who lose too much weight | 11.1% |
6.5%
4.6 pts worse
|
5.4%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 10.3% · Q3 3.1% · Q4 19.4% · 4Q avg 11.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.6% |
16.1%
15.5 pts worse
|
19.6%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 33.3% · Q3 30.3% · Q4 35.5% · 4Q avg 31.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 35.3% |
24.1%
11.2 pts worse
|
16.7%
18.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 39.3% · Q3 41.7% · Q4 20.0% · 4Q avg 35.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 44.3% |
18.5%
25.8 pts worse
|
16.3%
28 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 44.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 36.1% |
18.7%
17.4 pts worse
|
14.9%
21.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 44.7% · Q3 37.5% · Q4 35.5% · 4Q avg 36.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 7.6% |
1.9%
5.7 pts worse
|
1.0%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 9.5% · Q4 3.5% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
3.0%
1.6 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 6.2% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.8% |
23.6%
0.2 pts worse
|
19.8%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.5% · Q2 6.8% · Q3 19.0% · Q4 30.9% · 4Q avg 23.8% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
5.0%
0.4 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.2% · Q3 6.4% · Q4 5.9% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 53.1% |
75.7%
22.6 pts worse
|
81.7%
28.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 55.0% · Q3 40.9% · Q4 60.0% · 4Q avg 53.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.2% |
13.7%
3.5 pts better
|
12.0%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 10.0% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.6%
1.6 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.4% |
20.8%
5.4 pts better
|
23.9%
8.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.4% · Observed 15.0% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-02 · Fire 2024-05-02
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-03-31 · Fire 2023-03-31
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-08-07
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2025-08-30
D · Potential for more than minimal harm
2024-05-02
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-05-26
D · Potential for more than minimal harm
2024-05-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-26
F · Potential for more than minimal harm
2023-03-31
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-05-30
E · Potential for more than minimal harm
2023-03-31
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-04-24
E · Potential for more than minimal harm
2023-03-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-04
E · Potential for more than minimal harm
2023-03-31
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-04-07
E · Potential for more than minimal harm
2023-03-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-03-31
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-03-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-04
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-07
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-08-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-08-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-06-27
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-07-04
J · Immediate jeopardy
2024-05-02
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-05-03
E · Potential for more than minimal harm
2024-05-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-26
D · Potential for more than minimal harm
2024-05-02
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-26
J · Immediate jeopardy
2023-03-31
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-04-27
E · Potential for more than minimal harm
2023-03-31
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-31
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-31
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-31
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-02
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2023-03-29
Penalties and ownership
What sits behind the stars
$14,433
2024-05-02
Fine
Fine · fine $14,433
Fine
Ownership
Nearby options
Other facilities in reach
#1
Shepherd of the Valley Rehabilitation and Wellness
Casper, WY
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $78,536 in total fines with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Casper Mountain Rehabilitation and Care Center
Casper, WY
1-star overall rating with 1-star inspections with Special Focus status with $116,051 in total fines with 30 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Life Care Center of Casper
Casper, WY
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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