Cheyenne, WY

Granite Rehabilitation and Wellness

2-star overall rating with 2-star inspections with $15,548 in total fines with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle

3128 Boxelder Dr, Cheyenne, WY

(307) 634-7901

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

146

Certified beds

Average residents

87

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Evergreen Healthcare Group

Operator or chain grouping

Approved since

1973-04-01

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

0.63

Registered nurse staffing · state 0.90 · national 0.68

LPN hours / resident day

0.71

Licensed practical nurse staffing · state 0.48 · national 0.87

Aide hours / resident day

1.81

Nurse aide staffing · state 2.46 · national 2.35

Total nurse hours

3.16

All reported nurse hours · state 3.84 · national 3.89

Licensed hours

1.34

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.95

Weekend nurse staffing · state 3.30 · national 3.43

Weekend RN hours

0.52

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

0.73

CMS adjusted RN staffing hours

Adjusted total hours

3.63

CMS adjusted total nurse staffing hours

Case-mix index

1.19

Higher values indicate more complex resident acuity

RN turnover

50%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

48%

Annual nurse turnover · state 53% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,385

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

Performance score

20.56

Composite VBP score used to determine payment impact.

Payment multiplier

0.9824

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.87

Baseline 21.23% · Performance 19.64% · Measure score 3.87 · Achievement 3.87 · Improvement 3.29

Healthcare-associated infections

0.29

Baseline 8.57% · Performance 8.28% · Measure score 0.29 · Achievement 0 · Improvement 0.29

Total nurse turnover

2.69

Baseline 53.75% · Performance 52.70% · Measure score 2.69 · Achievement 2.69 · Improvement 0

Adjusted total nurse staffing

1.38

Baseline 2.84 hours · Performance 3.39 hours · Measure score 1.38 · Achievement 1.10 · Improvement 1.38

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 9.12%
10.72%
1.6 pts better
No Different than the National Rate · Eligible stays 148 · Observed rate 6.76% · Lower 95% interval 6.15%
Discharge to community 48.95%
50.57%
1.6 pts worse
No Different than the National Rate · Eligible stays 131 · Observed rate 42.75% · Lower 95% interval 40.65%
Medicare spending per beneficiary 1.15
1.02
0.1 pts worse
Drug regimen review with follow-up 98.02%
95.27%
2.8 pts better
Numerator 99 · Denominator 101
Falls with major injury 0.99%
0.77%
0.2 pts worse
Numerator 1 · Denominator 101
Discharge self-care score 28.07%
53.69%
25.6 pts worse
Numerator 16 · Denominator 57
Discharge mobility score 31.58%
50.94%
19.4 pts worse
Numerator 18 · Denominator 57
Pressure ulcers or injuries, new or worsened 2.97%
2.29%
0.7 pts worse
Numerator 3 · Denominator 101 · Adjusted rate 2.4%
Healthcare-associated infections requiring hospitalization 8.28%
7.12%
1.2 pts worse
No Different than the National Rate · Eligible stays 89 · Observed rate 10.11% · Lower 95% interval 5.35%
Staff COVID-19 vaccination coverage 4.48%
8.2%
3.7 pts worse
Numerator 6 · Denominator 134
Staff flu vaccination coverage 81.86%
42%
39.9 pts better
Numerator 176 · Denominator 215
Discharge function score 35.09%
56.45%
21.4 pts worse
Numerator 20 · Denominator 57
Transfer of health information to provider 100%
95.95%
4 pts better
Numerator 37 · Denominator 37
Transfer of health information to patient 88.89%
96.28%
7.4 pts worse
Numerator 24 · Denominator 27
Resident COVID-19 vaccinations up to date 33.33%
25.2%
8.1 pts better
Numerator 16 · Denominator 48

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 1.5
1.3
0.2 pts worse
1.9
0.4 pts better
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.7 · Expected 2.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 1.4
2.2
0.8 pts better
1.8
0.4 pts better
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 94.6%
94.3%
0.3 pts better
93.4%
1.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 93.2% · Q2 94.7% · Q3 94.5% · Q4 95.9% · 4Q avg 94.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 97.6%
94.3%
3.3 pts better
95.5%
2.1 pts better
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6%
Percentage of long-stay residents experiencing one or more falls with major injury 2.0%
4.8%
2.8 pts better
3.3%
1.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.7% · Q3 2.7% · Q4 1.4% · 4Q avg 2.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 4.0%
6.4%
2.4 pts better
11.4%
7.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 4.3% · Q3 1.5% · Q4 4.3% · 4Q avg 4.0%
Percentage of long-stay residents who lose too much weight 2.4%
6.5%
4.1 pts better
5.4%
3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.4% · Q4 6.6% · 4Q avg 2.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 18.2%
16.1%
2.1 pts worse
19.6%
1.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 17.6% · Q3 19.7% · Q4 20.3% · 4Q avg 18.2%
Percentage of long-stay residents who received an antipsychotic medication 23.3%
24.1%
0.8 pts better
16.7%
6.6 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 27.6% · Q3 27.5% · Q4 20.8% · 4Q avg 23.3% · 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 26.5%
18.5%
8 pts worse
16.3%
10.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 54.2% · Q2 21.8% · Q3 14.5% · Q4 12.8% · 4Q avg 26.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 19.4%
18.7%
0.7 pts worse
14.9%
4.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 35.9% · Q2 18.5% · Q3 15.0% · Q4 7.8% · 4Q avg 19.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.0%
1.9%
1.9 pts better
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% · 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 1.4% · Q2 1.4% · Q3 1.4% · Q4 1.4% · 4Q avg 1.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 25.9%
23.6%
2.3 pts worse
19.8%
6.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 36.6% · Q2 21.5% · Q3 24.8% · Q4 20.2% · 4Q avg 25.9%
Percentage of long-stay residents with pressure ulcers 0.9%
5.0%
4.1 pts better
5.1%
4.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 1.8% · 4Q avg 0.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 50.5%
75.7%
25.2 pts worse
81.7%
31.2 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 50.9% · Q2 49.2% · Q3 49.3% · Q4 52.6% · 4Q avg 50.5%
Percentage of short-stay residents who had an outpatient emergency department visit 14.1%
13.7%
0.4 pts worse
12.0%
2.1 pts worse
Short Stay · 20240701-20250630 · Adjusted 14.1% · Observed 14.3% · Expected 11.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 0.9%
1.6%
0.7 pts better
1.6%
0.7 pts better
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 36.4%
77.0%
40.6 pts worse
79.7%
43.3 pts worse
Short Stay · 2024Q3-2025Q2 · 4Q avg 36.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 37.4%
20.8%
16.6 pts worse
23.9%
13.5 pts worse
Short Stay · 20240701-20250630 · Adjusted 37.4% · Observed 37.1% · Expected 23.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-08-07 · Fire 2024-08-07

9 health deficiencies

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

9 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 2 Health 2023-05-25 · Fire 2023-05-25

10 health deficiencies

Top issue: Nutrition and Dietary (4 deficiencies)

12 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2022-04-14 · Fire 2022-04-14

6 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2024-12-11

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-01-02

F · Potential for more than minimal harm 2024-08-07

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-08-31

E · Potential for more than minimal harm 2024-08-07

K355 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-08-31

E · Potential for more than minimal harm 2024-08-07

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 2024-08-31

D · Potential for more than minimal harm 2024-08-07

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2024-08-31

D · Potential for more than minimal harm 2024-08-07

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-08-31

D · Potential for more than minimal harm 2024-08-07

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-08-31

D · Potential for more than minimal harm 2024-08-07

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-08-31

D · Potential for more than minimal harm 2024-08-07

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-08-31

D · Potential for more than minimal harm 2024-08-07

K929 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

Corrected 2024-08-31

F · Potential for more than minimal harm 2023-05-25

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2023-06-23

F · Potential for more than minimal harm 2023-05-25

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2023-06-23

F · Potential for more than minimal harm 2023-05-25

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-06-23

F · Potential for more than minimal harm 2023-05-25

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-06-23

F · Potential for more than minimal harm 2023-05-25

K531 · Services Deficiencies

Fire Safety

Have elevators that firefighters can control in the event of a fire.

Corrected 2023-06-23

F · Potential for more than minimal harm 2023-05-25

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2023-06-23

E · Potential for more than minimal harm 2023-05-25

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-06-23

E · Potential for more than minimal harm 2023-05-25

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-06-23

D · Potential for more than minimal harm 2023-05-25

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2023-06-23

D · Potential for more than minimal harm 2023-05-25

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2023-06-23

D · Potential for more than minimal harm 2023-05-25

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-06-23

E · Potential for more than minimal harm 2022-04-14

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2022-04-22

E · Potential for more than minimal harm 2022-04-14

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2022-04-22

E · Potential for more than minimal harm 2022-04-14

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2022-04-22

E · Potential for more than minimal harm 2022-04-14

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2022-04-22

E · Potential for more than minimal harm 2022-04-14

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-04-22

E · Potential for more than minimal harm 2022-04-14

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2022-05-26

D · Potential for more than minimal harm 2022-04-14

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 2022-04-22

D · Potential for more than minimal harm 2022-04-14

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2022-04-22

Inspection history

Recent health citations

G · Actual harm 2025-06-24

F740 · Quality of Life and Care Deficiencies

Health

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected 2025-07-19

D · Potential for more than minimal harm 2025-06-24

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 2025-07-19

F · Potential for more than minimal harm 2024-08-07

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2024-09-09

E · Potential for more than minimal harm 2024-08-07

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 2024-09-09

E · Potential for more than minimal harm 2024-08-07

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2024-09-09

D · Potential for more than minimal harm 2024-08-07

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-09-09

D · Potential for more than minimal harm 2024-08-07

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2024-09-09

D · Potential for more than minimal harm 2024-08-07

F742 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Corrected 2024-09-09

D · Potential for more than minimal harm 2024-08-07

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-09-09

F · Potential for more than minimal harm 2024-04-12

F802 · Nutrition and Dietary Deficiencies

Health

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Corrected 2024-05-13

E · Potential for more than minimal harm 2024-04-12

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 2024-05-13

E · Potential for more than minimal harm 2024-04-12

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 2024-05-13

E · Potential for more than minimal harm 2024-04-12

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-05-13

D · Potential for more than minimal harm 2024-04-12

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-05-13

E · Potential for more than minimal harm 2023-10-11

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-10-29

F · Potential for more than minimal harm 2023-05-25

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 2023-06-23

E · Potential for more than minimal harm 2023-05-25

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-06-23

D · Potential for more than minimal harm 2023-05-25

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2023-06-23

D · Potential for more than minimal harm 2023-05-25

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 2023-06-23

D · Potential for more than minimal harm 2023-05-25

F800 · Nutrition and Dietary Deficiencies

Health

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Corrected 2023-06-23

D · Potential for more than minimal harm 2023-03-07

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2023-03-31

F · Potential for more than minimal harm 2022-04-14

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 2022-04-23

E · Potential for more than minimal harm 2022-04-14

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 2022-04-23

E · Potential for more than minimal harm 2022-04-14

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-04-23

D · Potential for more than minimal harm 2022-04-14

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2022-04-23

Penalties and ownership

What sits behind the stars

$15,548 2025-06-24

Fine

Fine · fine $15,548

Fine

Ownership

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