Cycle 1
Health 2024-10-10 · Fire 2024-10-10
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Laramie, WY
Laramie Health and Rehabilitation
2-star overall rating with 2-star inspections with $43,618 in total fines with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
503 S 18th St, Laramie, WY
(307) 742-3728
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
105
Certified beds
Average residents
55
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Evergreen Healthcare Group
Operator or chain grouping
Approved since
1991-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.50
Registered nurse staffing
LPN hours / resident day
0.80
Licensed practical nurse staffing
Aide hours / resident day
1.84
Nurse aide staffing
Weekend hours
2.69
Weekend nurse staffing
RN turnover
57%
Annual RN turnover
Total nurse turnover
47%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| 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 | 1.5 |
2.2
0.7 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 66.1% |
94.3%
28.2 pts worse
|
93.4%
27.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 77.6% |
94.3%
16.7 pts worse
|
95.5%
17.9 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
4.8%
3.1 pts better
|
3.3%
1.6 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 | 3.9% |
6.5%
2.6 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.3% |
16.1%
7.8 pts better
|
19.6%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 20.3% |
24.1%
3.8 pts better
|
16.7%
3.6 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 | 25.7% |
18.5%
7.2 pts worse
|
16.3%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.1% |
18.7%
1.6 pts better
|
14.9%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.9%
0.9 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
3.0%
1.8 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.5% |
23.6%
5.1 pts better
|
19.8%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 10.6% |
5.0%
5.6 pts worse
|
5.1%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 57.6% |
75.7%
18.1 pts worse
|
81.7%
24.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.3% |
13.7%
0.4 pts better
|
12.0%
1.3 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.6%
0.1 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 60.0% |
77.0%
17 pts worse
|
79.7%
19.7 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.6% |
20.8%
0.8 pts worse
|
23.9%
2.3 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-27 · Fire 2023-07-27
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-06-09 · Fire 2022-06-09
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-10
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-29
E · Potential for more than minimal harm
2024-10-10
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-10
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 2024-10-10
D · Potential for more than minimal harm
2024-10-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-10-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-18
F · Potential for more than minimal harm
2023-07-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-24
E · Potential for more than minimal harm
2023-07-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-11
D · Potential for more than minimal harm
2023-07-27
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 2023-08-24
D · Potential for more than minimal harm
2023-07-27
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 2023-08-24
D · Potential for more than minimal harm
2023-07-27
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-08-24
F · Potential for more than minimal harm
2022-06-09
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-07-13
F · Potential for more than minimal harm
2022-06-09
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-10-06
F · Potential for more than minimal harm
2022-06-09
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2022-07-03
F · Potential for more than minimal harm
2022-06-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-06-15
F · Potential for more than minimal harm
2022-06-09
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-09-09
E · Potential for more than minimal harm
2022-06-09
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-08-31
E · Potential for more than minimal harm
2022-06-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-06-30
E · Potential for more than minimal harm
2022-06-09
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-07-31
E · Potential for more than minimal harm
2022-06-09
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2022-07-03
E · Potential for more than minimal harm
2022-06-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-07-03
D · Potential for more than minimal harm
2022-06-09
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-06-09
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2022-07-13
D · Potential for more than minimal harm
2022-06-09
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 2022-08-31
D · Potential for more than minimal harm
2022-06-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-06-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-06-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-09-28
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-10-10
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 2024-11-01
F · Potential for more than minimal harm
2024-10-10
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-11-24
E · Potential for more than minimal harm
2024-10-10
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-11-24
E · Potential for more than minimal harm
2024-10-10
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 2024-11-24
E · Potential for more than minimal harm
2024-10-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-10-10
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2024-11-24
D · Potential for more than minimal harm
2024-10-10
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 2024-11-24
G · Actual harm
2024-05-22
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 2024-06-13
G · Actual harm
2023-07-27
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 2023-07-19
F · Potential for more than minimal harm
2023-07-27
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 2023-08-24
F · Potential for more than minimal harm
2023-07-27
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 2023-08-24
E · Potential for more than minimal harm
2023-07-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-24
E · Potential for more than minimal harm
2023-07-27
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-08-24
D · Potential for more than minimal harm
2023-07-27
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 2023-08-24
D · Potential for more than minimal harm
2023-07-27
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 2023-08-24
D · Potential for more than minimal harm
2023-07-27
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 2023-08-24
G · Actual harm
2023-03-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-17
D · Potential for more than minimal harm
2023-03-14
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 2023-04-17
D · Potential for more than minimal harm
2023-03-14
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 2023-04-17
D · Potential for more than minimal harm
2022-06-09
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-07-13
D · Potential for more than minimal harm
2022-06-09
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 2022-07-13
D · Potential for more than minimal harm
2022-06-09
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 2022-07-13
D · Potential for more than minimal harm
2022-06-09
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-07-13
D · Potential for more than minimal harm
2022-06-09
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 2022-07-13
D · Potential for more than minimal harm
2022-06-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-13
B · Minimal harm
2022-06-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-07-13
Penalties and ownership
What sits behind the stars
$35,880
2024-05-22
Fine
Fine · fine $35,880
Fine
$7,738
2023-07-27
Fine
Fine · fine $7,738
Fine
Ownership
Sptihs Properties Trust
5% Or Greater Direct Ownership Interest · Organization
Abp Trust
5% Or Greater Indirect Ownership Interest · Organization
Abp Trust
Operational/Managerial Control · Organization
Benton, Evrett
Operational/Managerial Control · Individual
Bilotto, Christopher
Operational/Managerial Control · Individual
Bilotto, Christopher
Corporate Director · Individual
Bilotto, Christopher
Corporate Officer · Individual
Blackrock Inc
5% Or Greater Indirect Ownership Interest · Organization
Blackrock Inc
Operational/Managerial Control · Organization
Brown, Matthew
Operational/Managerial Control · Individual
Brown, Matthew
Corporate Officer · Individual
Charles Schwab Investment Management, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Charles Schwab Investment Management, Inc.
Operational/Managerial Control · Organization
Clark, Jennifer
Operational/Managerial Control · Individual
Clark, Jennifer
Corporate Officer · Individual
D.e. Shaw & Co., L.p.
5% Or Greater Indirect Ownership Interest · Organization
D.e. Shaw & Co., L.p.
Operational/Managerial Control · Organization
Diversified Healthcare Trust
5% Or Greater Indirect Ownership Interest · Organization
Diversified Healthcare Trust
Operational/Managerial Control · Organization
Flat Footed LLC
5% Or Greater Indirect Ownership Interest · Organization
Flat Footed LLC
Operational/Managerial Control · Organization
H/2 Special Opportunities Iv L.p.
5% Or Greater Indirect Ownership Interest · Organization
H/2 Special Opportunities Iv L.p.
Operational/Managerial Control · Organization
Kaufman, Trent
Operational/Managerial Control · Individual
Mikesell, Darren
Operational/Managerial Control · Individual
Montez, Lisa
Operational/Managerial Control · Individual
Portnoy, Adam
5% Or Greater Indirect Ownership Interest · Individual
Portnoy, Adam
Operational/Managerial Control · Individual
Portnoy, Adam
Corporate Director · Individual
Snh Proj Lincoln Trs LLC
5% Or Greater Indirect Ownership Interest · Organization
Snh Proj Lincoln Trs LLC
Operational/Managerial Control · Organization
Snh Trs Licensee Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Snh Trs Licensee Holdco LLC
Operational/Managerial Control · Organization
Snh Trs, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Snh Trs, Inc.
Operational/Managerial Control · Organization
Sptihs Properties Trust
Operational/Managerial Control · Organization
Stellar Laramie Management LLC
Operational/Managerial Control · Organization
Stellar Senior Living B LLC
Operational/Managerial Control · Organization
Stellar V LLC
Operational/Managerial Control · Organization
Vanguard Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Vanguard Group Inc
Operational/Managerial Control · Organization
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#3
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