Pinedale, WY
3-star overall rating with 3-star inspections with $9,718 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
333 N Bridger Ave, Pinedale, WY
(307) 367-4161
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
50
Certified beds
Average residents
37
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1982-05-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
1.21
Registered nurse staffing · state 0.90 · national 0.68
LPN hours / resident day
0.10
Licensed practical nurse staffing · state 0.48 · national 0.87
Aide hours / resident day
2.18
Nurse aide staffing · state 2.46 · national 2.35
Total nurse hours
3.50
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
2.88
Weekend nurse staffing · state 3.30 · national 3.43
Weekend RN hours
0.86
Weekend registered nurse coverage · state 0.62 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.47
CMS adjusted RN staffing hours
Adjusted total hours
4.23
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
92%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
98%
Annual nurse turnover · state 53% · national 46%
SNF VBP
Program rank
5,968
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.43
Composite VBP score used to determine payment impact.
Payment multiplier
0.9884
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.03
Baseline 30.00% · Performance 51.28% · Measure score 3.03 · Achievement 3.03 · Improvement 0
Adjusted total nurse staffing
3.85
Baseline 3.72 hours · Performance 4.17 hours · Measure score 3.85 · Achievement 3.85 · Improvement 1.68
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.43% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 0% · Lower 95% interval 5.81% |
| Discharge to community | 53.21% |
50.57%
2.6 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 54.84% · Lower 95% interval 39.82% |
| Medicare spending per beneficiary | 0.49 |
1.02
0.5 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 21 · Denominator 21 |
| Falls with major injury | 4.76% |
0.77%
4 pts worse
|
Numerator 1 · Denominator 21 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 10 · Denominator 20 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 10 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 4.76% |
2.29%
2.5 pts worse
|
Numerator 1 · Denominator 21 · Adjusted rate 5.62% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 10% |
8.2%
1.8 pts better
|
Numerator 7 · Denominator 70 |
| Staff flu vaccination coverage | 28.05% |
42%
13.9 pts worse
|
Numerator 23 · Denominator 82 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 12 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
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 · Adjusted 1.1 · Observed 0.8 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0 |
2.2
2.2 pts better
|
1.8
1.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
94.3%
2.5 pts better
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 88.2% · 4Q avg 96.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.3%
5.7 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.2% |
4.8%
2.4 pts worse
|
3.3%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 3.3% · Q3 7.7% · Q4 5.9% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.8% |
6.4%
0.4 pts worse
|
11.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 6.9% · Q3 7.7% · Q4 6.9% · 4Q avg 6.8% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
6.5%
1.3 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 3.7% · Q3 0.0% · Q4 6.1% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.9% |
16.1%
6.8 pts worse
|
19.6%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 25.0% · Q3 25.0% · Q4 21.2% · 4Q avg 22.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 36.7% |
24.1%
12.6 pts worse
|
16.7%
20 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.5% · Q2 39.1% · Q3 42.9% · Q4 32.0% · 4Q avg 36.7% · 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 | 22.1% |
18.5%
3.6 pts worse
|
16.3%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 20.2% · Q4 39.9% · 4Q avg 22.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.1% |
18.7%
0.4 pts worse
|
14.9%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 18.5% · Q3 17.4% · Q4 28.1% · 4Q avg 19.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.8% |
1.9%
4.9 pts worse
|
1.0%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 5.0% · Q3 4.1% · Q4 3.0% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.7% |
3.0%
2.7 pts worse
|
1.7%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 10.3% · Q3 8.0% · Q4 5.9% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.9% |
23.6%
3.7 pts better
|
19.8%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 17.6% · Q3 22.9% · Q4 15.9% · 4Q avg 19.9% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
5.0%
0.6 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 0.0% · Q3 0.0% · Q4 3.5% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.8% |
75.7%
3.1 pts better
|
81.7%
2.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 71.4% · Q4 70.4% · 4Q avg 78.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
13.7%
13.7 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.6%
0.6 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 5.0% |
20.8%
15.8 pts better
|
23.9%
18.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.0% · Observed 4.3% · Expected 20.7% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Top issue: Pharmacy Service (2 deficiencies)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-07-11
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 2024-03-08
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-02-23
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-08
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2023-03-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-23
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-08
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-03-02
Inspection history
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-09-10
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-11
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-11
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-07-11
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-28
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-05-28
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-04
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-20
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 2024-03-20
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-02-28
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 2023-02-28
Penalties and ownership
Fine · fine $9,718
Fine
Operational/Managerial Control · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Operational/Managerial Control · Individual
Contracted Managing Employee · Individual
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
W-2 Managing Employee · Individual
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