Green River, WY
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1445 Uinta Dr, Green River, WY
(307) 872-4600
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
59
Certified beds
Average residents
46
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Mission Health Services
Operator or chain grouping
Approved since
1989-01-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
0.79
Registered nurse staffing · state 0.90 · national 0.68
LPN hours / resident day
0.52
Licensed practical nurse staffing · state 0.48 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.46 · national 2.35
Total nurse hours
3.43
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 3.30 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.62 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
3.45
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 53% · national 46%
SNF VBP
Program rank
9,948
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.96
Composite VBP score used to determine payment impact.
Payment multiplier
0.9827
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 16.81% · Performance 21.27% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.93
Baseline 5.59% · Performance 6.66% · Measure score 3.93 · Achievement 3.93 · Improvement 0
Total nurse turnover
3.86
Baseline 41.86% · Performance 47.92% · Measure score 3.86 · Achievement 3.86 · Improvement 0
Adjusted total nurse staffing
0.99
Baseline 3.17 hours · Performance 3.36 hours · Measure score 0.99 · Achievement 0.99 · Improvement 0.24
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.61% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 188 · Observed rate 6.91% · Lower 95% interval 7.09% |
| Discharge to community | 60.56% |
50.57%
10 pts better
|
Better than the National Rate · Eligible stays 176 · Observed rate 61.93% · Lower 95% interval 52.76% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 106 · Denominator 106 |
| Falls with major injury | 2.83% |
0.77%
2.1 pts worse
|
Numerator 3 · Denominator 106 |
| Discharge self-care score | 75% |
53.69%
21.3 pts better
|
Numerator 63 · Denominator 84 |
| Discharge mobility score | 64.29% |
50.94%
13.4 pts better
|
Numerator 54 · Denominator 84 |
| Pressure ulcers or injuries, new or worsened | 0.94% |
2.29%
1.4 pts better
|
Numerator 1 · Denominator 106 · Adjusted rate 1.19% |
| Healthcare-associated infections requiring hospitalization | 6.66% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 111 · Observed rate 4.5% · Lower 95% interval 3.61% |
| Staff COVID-19 vaccination coverage | 8.26% |
8.2%
0.1 pts better
|
Numerator 9 · Denominator 109 |
| Staff flu vaccination coverage | 27.21% |
42%
14.8 pts worse
|
Numerator 40 · Denominator 147 |
| Discharge function score | 71.43% |
56.45%
15 pts better
|
Numerator 60 · Denominator 84 |
| Transfer of health information to provider | 95% |
95.95%
1 pts worse
|
Numerator 19 · Denominator 20 |
| Transfer of health information to patient | 96.83% |
96.28%
0.5 pts better
|
Numerator 61 · Denominator 63 |
| Resident COVID-19 vaccinations up to date | 20.83% |
25.2%
4.4 pts worse
|
Numerator 10 · Denominator 48 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.3
About the same
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.9 · 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 2.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
94.3%
5 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.3% · 4Q avg 99.3% |
| 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 | 6.8% |
4.8%
2 pts worse
|
3.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 5.4% · Q3 3.2% · Q4 5.4% · 4Q avg 6.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.8% |
6.5%
5.7 pts better
|
5.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.6% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.1% |
16.1%
4 pts worse
|
19.6%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 22.6% · Q3 24.1% · Q4 14.3% · 4Q avg 20.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.8% |
24.1%
6.3 pts better
|
16.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 17.4% · Q3 13.0% · Q4 22.2% · 4Q avg 17.8% · 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 | 11.9% |
18.5%
6.6 pts better
|
16.3%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.1% |
18.7%
5.6 pts better
|
14.9%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 3.3% · Q3 3.6% · Q4 11.8% · 4Q avg 13.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.9%
0.4 pts better
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
3.0%
0.9 pts better
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.3% · Q4 5.6% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.9% |
23.6%
3.3 pts worse
|
19.8%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 33.0% · Q3 34.4% · Q4 26.4% · 4Q avg 26.9% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
5.0%
2.1 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.6% · Q3 0.0% · Q4 6.1% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.7% |
75.7%
8 pts better
|
81.7%
2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 80.0% · Q2 83.6% · Q3 85.3% · Q4 84.8% · 4Q avg 83.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.4% |
13.7%
1.7 pts worse
|
12.0%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.4% · Observed 14.7% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.6%
0.3 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.4% |
77.0%
14.4 pts better
|
79.7%
11.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.1% |
20.8%
0.3 pts worse
|
23.9%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 21.3% · Expected 24.1% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Resident Rights (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-05-23
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-05-23
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-23
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-23
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-23
Fire Safety
Meet requirements for the installation and maintenance of medical gas and medical vacuum systems.
Corrected 2025-05-23
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-29
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-12-01
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-12-01
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-12-12
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-01
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-01
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-02
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-23
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 2024-02-16
Health
Provide activities to meet all resident's needs.
Corrected 2024-02-16
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-02-16
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-02-16
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-12-29
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-12-01
Health
Ensure that paid feeding assistants have the training they need.
Corrected 2022-12-01
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-12-01
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 2022-12-01
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-12-01
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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