9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cheyenne, WY
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
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
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
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
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
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
| 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
| 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
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Nutrition and Dietary (4 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-02
Fire Safety
Meet other general requirements.
Corrected 2024-08-31
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-08-31
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
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
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-31
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-08-31
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-31
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-31
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-08-31
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-06-23
Fire Safety
Meet other general requirements.
Corrected 2023-06-23
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-23
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-23
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-06-23
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-23
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-23
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-06-23
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
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-06-23
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-23
Fire Safety
Meet other general requirements.
Corrected 2022-04-22
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
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-04-22
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-04-22
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-04-22
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-05-26
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
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-04-22
Inspection history
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-07-19
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
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
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
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
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
Health
Provide activities to meet all resident's needs.
Corrected 2024-09-09
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
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-09
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-05-13
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
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-13
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-05-13
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-13
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-29
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
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-23
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
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
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
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-03-31
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
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-04-23
Health
Provide and implement an infection prevention and control program.
Corrected 2022-04-23
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
Fine · fine $15,548
Fine
Nearby options
Cheyenne, WY
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $62,647 in total fines with 21 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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Fort Collins, CO
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