Torrington, WY

Goshen Healthcare Community

3-star overall rating with 3-star inspections with $29,617 in total fines with 7 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle

2009 Laramie St, Torrington, WY

(307) 532-4038

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

103

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2017-07-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

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

0.56

Registered nurse staffing · state 0.90 · national 0.68

LPN hours / resident day

0.63

Licensed practical nurse staffing · state 0.48 · national 0.87

Aide hours / resident day

2.01

Nurse aide staffing · state 2.46 · national 2.35

Total nurse hours

3.20

All reported nurse hours · state 3.84 · national 3.89

Licensed hours

1.19

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.91

Weekend nurse staffing · state 3.30 · national 3.43

Weekend RN hours

0.32

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

0.65

CMS adjusted RN staffing hours

Adjusted total hours

3.71

CMS adjusted total nurse staffing hours

Case-mix index

1.18

Higher values indicate more complex resident acuity

RN turnover

77%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

53%

Annual nurse turnover · state 53% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,579

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

29.38

Composite VBP score used to determine payment impact.

Payment multiplier

0.9854

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.25

Baseline 19.03% · Performance 20.39% · Measure score 2.25 · Achievement 2.25 · Improvement 0

Healthcare-associated infections

5.20

Baseline 5.28% · Performance 6.28% · Measure score 5.20 · Achievement 5.20 · Improvement 0

Total nurse turnover

0.83

Baseline 60.29% · Performance 60.29% · Measure score 0.83 · Achievement 0.83 · Improvement 0

Adjusted total nurse staffing

3.48

Baseline 3.56 hours · Performance 4.07 hours · Measure score 3.48 · Achievement 3.48 · Improvement 1.80

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.05%	10.72% 0.7 pts better	No Different than the National Rate · Eligible stays 74 · Observed rate 6.76% · Lower 95% interval 6.27%
Discharge to community	39.96%	50.57% 10.6 pts worse	Worse than the National Rate · Eligible stays 80 · Observed rate 35% · Lower 95% interval 30.95%
Medicare spending per beneficiary	1.16	1.02 0.1 pts worse
Drug regimen review with follow-up	98.04%	95.27% 2.8 pts better	Numerator 50 · Denominator 51
Falls with major injury	1.96%	0.77% 1.2 pts worse	Numerator 1 · Denominator 51
Discharge self-care score	72.73%	53.69% 19 pts better	Numerator 24 · Denominator 33
Discharge mobility score	57.58%	50.94% 6.6 pts better	Numerator 19 · Denominator 33
Pressure ulcers or injuries, new or worsened	5.88%	2.29% 3.6 pts worse	Numerator 3 · Denominator 51 · Adjusted rate 9.29%
Healthcare-associated infections requiring hospitalization	6.28%	7.12% 0.8 pts better	No Different than the National Rate · Eligible stays 64 · Observed rate 3.13% · Lower 95% interval 3.4%
Staff COVID-19 vaccination coverage	1.87%	8.2% 6.3 pts worse	Numerator 2 · Denominator 107
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score	63.64%	56.45% 7.2 pts better	Numerator 21 · Denominator 33
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 26 · Denominator 26
Resident COVID-19 vaccinations up to date	0%	25.2% 25.2 pts worse	Numerator 0 · Denominator 28

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.9	1.3 0.4 pts better	1.9 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.5	2.2 0.3 pts worse	1.8 0.7 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.4 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.1%	94.3% 3.8 pts better	93.4% 4.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 98.5% · Q3 100.0% · Q4 100.0% · 4Q avg 98.1%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.6%	94.3% 4.3 pts better	95.5% 3.1 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6%
Percentage of long-stay residents experiencing one or more falls with major injury	4.5%	4.8% 0.3 pts better	3.3% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 4.4% · Q3 6.2% · Q4 5.8% · 4Q avg 4.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.5%	6.4% 3.9 pts better	11.4% 8.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.3% · Q3 0.0% · Q4 4.5% · 4Q avg 2.5%
Percentage of long-stay residents who lose too much weight	3.1%	6.5% 3.4 pts better	5.4% 2.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 4.6% · Q3 4.9% · Q4 1.4% · 4Q avg 3.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	12.3%	16.1% 3.8 pts better	19.6% 7.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 13.6% · Q3 9.5% · Q4 11.6% · 4Q avg 12.3%
Percentage of long-stay residents who received an antipsychotic medication	16.6%	24.1% 7.5 pts better	16.7% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 19.2% · Q3 14.0% · Q4 13.8% · 4Q avg 16.6% · 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	13.1%	18.5% 5.4 pts better	16.3% 3.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 14.6% · Q3 11.6% · Q4 14.3% · 4Q avg 13.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	14.6%	18.7% 4.1 pts better	14.9% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 6.3% · Q3 18.3% · Q4 27.3% · 4Q avg 14.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.3%	1.9% 1.6 pts better	1.0% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	3.0% 3 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.8%	23.6% 1.2 pts worse	19.8% 5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 26.3% · Q3 32.1% · Q4 23.2% · 4Q avg 24.8%
Percentage of long-stay residents with pressure ulcers	6.4%	5.0% 1.4 pts worse	5.1% 1.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 4.6% · Q3 6.9% · Q4 3.3% · 4Q avg 6.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	89.8%	75.7% 14.1 pts better	81.7% 8.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 83.3% · Q2 89.7% · Q3 91.2% · Q4 96.6% · 4Q avg 89.8%
Percentage of short-stay residents who had an outpatient emergency department visit	25.9%	13.7% 12.2 pts worse	12.0% 13.9 pts worse	Short Stay · 20240701-20250630 · Adjusted 25.9% · Observed 23.3% · Expected 10.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.7%	1.6% 0.1 pts worse	1.6% 0.1 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 1.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	96.8%	77.0% 19.8 pts better	79.7% 17.1 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 96.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	7.9%	20.8% 12.9 pts better	23.9% 16 pts better	Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 6.7% · Expected 20.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-24 · Fire 2025-07-24

7 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

17 fire-safety deficiencies

Top issue: Smoke (7 deficiencies)

Cycle 2 Health 2024-04-18 · Fire 2024-04-18

9 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2023-01-26 · Fire 2023-01-26

9 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

12 fire-safety deficiencies

Top issue: Emergency Preparedness (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-07-24

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-09-19

F · Potential for more than minimal harm 2025-07-24

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-09-19

F · Potential for more than minimal harm 2025-07-24

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2025-09-19

F · Potential for more than minimal harm 2025-07-24

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2025-12-16

F · Potential for more than minimal harm 2025-07-24

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2025-09-19

F · Potential for more than minimal harm 2025-07-24

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-09-19

E · Potential for more than minimal harm 2025-07-24

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 2025-09-19

E · Potential for more than minimal harm 2025-07-24

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 2025-09-19

E · Potential for more than minimal harm 2025-07-24

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2025-09-19

E · Potential for more than minimal harm 2025-07-24

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-12-16

E · Potential for more than minimal harm 2025-07-24

K751 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of flammable curtains.

Corrected 2025-09-19

D · Potential for more than minimal harm 2025-07-24

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2025-09-19

D · Potential for more than minimal harm 2025-07-24

K325 · Smoke Deficiencies

Fire Safety

Have properly installed hallway dispensers for alcohol-based hand rub.

Corrected 2025-09-19

D · Potential for more than minimal harm 2025-07-24

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-09-19

D · Potential for more than minimal harm 2025-07-24

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-09-19

D · Potential for more than minimal harm 2025-07-24

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-09-19

D · Potential for more than minimal harm 2025-07-24

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-09-19

F · Potential for more than minimal harm 2024-04-18

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-05-17

F · Potential for more than minimal harm 2024-04-18

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-05-17

D · Potential for more than minimal harm 2024-04-18

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2024-05-17

D · Potential for more than minimal harm 2024-04-18

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 2024-05-17

F · Potential for more than minimal harm 2023-01-26

E24 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for volunteers.

Corrected 2023-02-25

F · Potential for more than minimal harm 2023-01-26

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2023-02-25

F · Potential for more than minimal harm 2023-01-26

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2023-02-15

F · Potential for more than minimal harm 2023-01-26

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2023-02-15

D · Potential for more than minimal harm 2023-01-26

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2023-02-15

D · Potential for more than minimal harm 2023-01-26

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 2023-02-22

D · Potential for more than minimal harm 2023-01-26

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-02-15

D · Potential for more than minimal harm 2023-01-26

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-02-15

D · Potential for more than minimal harm 2023-01-26

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-01-25

D · Potential for more than minimal harm 2023-01-26

K753 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of highly flammable decorations.

Corrected 2023-02-22

D · Potential for more than minimal harm 2023-01-26

K919 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use of electrical equipment.

Corrected 2023-02-22

D · Potential for more than minimal harm 2023-01-26

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-02-22

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-10-02

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 2025-10-22

E · Potential for more than minimal harm 2025-07-24

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-08-26

E · Potential for more than minimal harm 2025-07-24

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2025-08-26

D · Potential for more than minimal harm 2025-07-24

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-08-26

D · Potential for more than minimal harm 2025-07-24

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 2025-08-26

D · Potential for more than minimal harm 2025-07-24

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-08-26

D · Potential for more than minimal harm 2025-06-17

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-07-15

E · Potential for more than minimal harm 2025-02-04

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-12-19

D · Potential for more than minimal harm 2025-02-04

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 2025-03-12

D · Potential for more than minimal harm 2025-02-04

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-03-12

F · Potential for more than minimal harm 2024-04-18

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 2024-05-17

E · Potential for more than minimal harm 2024-04-18

F729 · Nursing and Physician Services Deficiencies

Health

Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.

Corrected 2024-05-17

E · Potential for more than minimal harm 2024-04-18

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2024-05-17

D · Potential for more than minimal harm 2024-04-18

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2024-05-17

D · Potential for more than minimal harm 2024-04-18

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-05-17

D · Potential for more than minimal harm 2024-04-18

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-05-17

D · Potential for more than minimal harm 2024-01-23

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2024-02-22

D · Potential for more than minimal harm 2024-01-23

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-02-22

D · Potential for more than minimal harm 2023-12-13

F887 · Infection Control Deficiencies

Health

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Corrected 2024-01-18

D · Potential for more than minimal harm 2023-09-20

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2023-10-18

D · Potential for more than minimal harm 2023-09-20

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2023-10-18

G · Actual harm 2023-01-26

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 2023-02-28

E · Potential for more than minimal harm 2023-01-26

F680 · Quality of Life and Care Deficiencies

Health

Ensure the activities program is directed by a qualified professional.

Corrected 2023-02-28

D · Potential for more than minimal harm 2023-01-26

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2023-02-28

D · Potential for more than minimal harm 2023-01-26

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-02-28

Penalties and ownership

What sits behind the stars

$0 2025-07-24

Payment Denial

Payment Denial · denial start 2025-10-24 · 53 days

53 day denial

$29,617 2024-04-18

Fine

Fine · fine $29,617

Fine

Ownership

Contris, Paul

5% Or Greater Indirect Ownership Interest · Individual

100% 1 facilities 2019-01-18

Vetras Healthcare LLC

5% Or Greater Direct Ownership Interest · Organization

99% 1 facilities 2019-01-18

Bowers, Amy