12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Sheridan, WY
1-star overall rating with 1-star inspections with Special Focus status with $103,408 in total fines with 12 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
2311 Shirley Cove, Sheridan, WY
(307) 672-0600
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
48
Certified beds
Average residents
33
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2012-08-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Weekend hours
0.00
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.3
0.2 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.4 |
2.2
2.2 pts worse
|
1.8
2.6 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.9% |
94.3%
9.4 pts worse
|
93.4%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.0% |
94.3%
2.3 pts worse
|
95.5%
3.5 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
4.8%
2 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.4%
6.4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 28.7% |
6.5%
22.2 pts worse
|
5.4%
23.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.3% |
16.1%
1.8 pts better
|
19.6%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 42.9% |
24.1%
18.8 pts worse
|
16.7%
26.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.3% |
18.5%
6.2 pts better
|
16.3%
4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.6% |
18.7%
6.9 pts worse
|
14.9%
10.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
1.9%
0.7 pts better
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 50.6% |
23.6%
27 pts worse
|
19.8%
30.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
5.0%
1.7 pts worse
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 33.3% |
75.7%
42.4 pts worse
|
81.7%
48.4 pts worse
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Top issue: Nursing and Physician Services (3 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Top issue: Resident Rights (5 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2025-04-18
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-04-18
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-18
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-18
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-18
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-18
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-18
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-18
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-02-22
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-12
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-17
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-30
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-02-22
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-26
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-22
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-22
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-12-09
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-12-06
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2022-12-09
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-10
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-05
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-12-09
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-12-05
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-06
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-18
Health
Implement a program that monitors antibiotic use.
Corrected 2025-05-22
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-05-16
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-18
Health
Provide activities to meet all resident's needs.
Corrected 2025-04-18
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 2025-05-22
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-05-22
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-05-16
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-04-18
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-04-18
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 2025-04-16
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-05-19
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 2024-05-04
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2024-07-01
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-04
Health
Post nurse staffing information every day.
Corrected 2024-05-04
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-05
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-02-23
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-02-23
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-23
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-23
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-05-15
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2023-05-15
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-05-15
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-09
Health
Implement a program that monitors antibiotic use.
Corrected 2022-12-10
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-12-09
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2022-12-11
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-12-08
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-19
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 2022-12-10
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2022-12-09
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-12-10
Penalties and ownership
Fine · fine $22,315
Fine
Fine · fine $62,205
Fine
Payment Denial · denial start 2025-05-08 · 29 days
29 day denial
Fine · fine $6,900
Fine
Payment Denial · denial start 2024-05-01 · 61 days
61 day denial
Fine · fine $7,443
Fine
Fine · fine $4,545
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
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Corporate Director · Individual
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Corporate Director · Individual
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Operational/Managerial Control · Organization
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Corporate Director · Individual
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Corporate Director · Individual
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