Gillette, WY
0-star overall rating with 0-star inspections with Special Focus status with abuse icon flag with $115,597 in total fines with 6 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
1000 S Douglas Way, Gillette, WY
(307) 688-7000
Overall
0 / 5
CMS overall stars
Health inspections
0 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
0 / 5
Resident outcomes and process measures
Quick facts
Beds
160
Certified beds
Average residents
84
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1984-06-16
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
0.97
Registered nurse staffing · state 0.90 · national 0.68
LPN hours / resident day
0.34
Licensed practical nurse staffing · state 0.48 · national 0.87
Aide hours / resident day
2.84
Nurse aide staffing · state 2.46 · national 2.35
Total nurse hours
4.15
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
3.60
Weekend nurse staffing · state 3.30 · national 3.43
Weekend RN hours
0.60
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
1.11
CMS adjusted RN staffing hours
Adjusted total hours
4.77
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
69%
Annual nurse turnover · state 53% · national 46%
SNF VBP
Program rank
2,092
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.85
Composite VBP score used to determine payment impact.
Payment multiplier
1.0063
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.81
Baseline 16.43% · Performance 18.74% · Measure score 5.81 · Achievement 5.81 · Improvement 0
Healthcare-associated infections
10
Baseline 4.98% · Performance 4.99% · Measure score 10 · Achievement 10 · Improvement 0
Total nurse turnover
0
Baseline 63.25% · Performance 67.13% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
4.93
Baseline 3.86 hours · Performance 4.48 hours · Measure score 4.93 · Achievement 4.93 · Improvement 2.71
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.66% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 205 · Observed rate 7.8% · Lower 95% interval 6.87% |
| Discharge to community | 55.83% |
50.57%
5.3 pts better
|
No Different than the National Rate · Eligible stays 189 · Observed rate 53.97% · Lower 95% interval 48.59% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.59% |
95.27%
3.3 pts better
|
Numerator 140 · Denominator 142 |
| Falls with major injury | 1.41% |
0.77%
0.6 pts worse
|
Numerator 2 · Denominator 142 |
| Discharge self-care score | 53.04% |
53.69%
0.6 pts worse
|
Numerator 61 · Denominator 115 |
| Discharge mobility score | 33.04% |
50.94%
17.9 pts worse
|
Numerator 38 · Denominator 115 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 142 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 4.99% |
7.12%
2.1 pts better
|
No Different than the National Rate · Eligible stays 134 · Observed rate 1.49% · Lower 95% interval 2.81% |
| Staff COVID-19 vaccination coverage | 1.14% |
8.2%
7.1 pts worse
|
Numerator 2 · Denominator 176 |
| Staff flu vaccination coverage | 81.68% |
42%
39.7 pts better
|
Numerator 156 · Denominator 191 |
| Discharge function score | 54.78% |
56.45%
1.7 pts worse
|
Numerator 63 · Denominator 115 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 75 · Denominator 75 |
| Transfer of health information to patient | 96.3% |
96.28%
About the same
|
Numerator 26 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 17.74% |
25.2%
7.5 pts worse
|
Numerator 11 · Denominator 62 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.3
0.1 pts worse
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.0 |
2.2
1.8 pts worse
|
1.8
2.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.0 · Observed 3.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
94.3%
0.6 pts better
|
93.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.1% · Q2 89.8% · Q3 95.9% · Q4 100.0% · 4Q avg 94.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.5% |
94.3%
3.8 pts worse
|
95.5%
5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.8% |
4.8%
3 pts worse
|
3.3%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 7.4% · Q3 9.3% · Q4 9.2% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.1% |
6.4%
5.7 pts worse
|
11.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 20.7% · Q3 7.4% · Q4 7.2% · 4Q avg 12.1% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
6.5%
0.3 pts better
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 10.0% · Q3 7.5% · Q4 0.0% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.1% |
16.1%
1 pts better
|
19.6%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 15.3% · Q3 14.9% · Q4 15.2% · 4Q avg 15.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.3% |
24.1%
8.8 pts better
|
16.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 13.0% · Q3 11.3% · Q4 16.7% · 4Q avg 15.3% · 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 | 16.2% |
18.5%
2.3 pts better
|
16.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 30.1% · Q2 19.8% · Q3 9.0% · Q4 3.7% · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.5% |
18.7%
0.8 pts worse
|
14.9%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 26.3% · Q3 13.4% · Q4 7.9% · 4Q avg 19.5% · Used in QM five-star |
| 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 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.8% |
3.0%
0.8 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 7.0% · Q3 2.2% · Q4 2.4% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.7% |
23.6%
4.1 pts worse
|
19.8%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 31.5% · Q3 24.1% · Q4 31.4% · 4Q avg 27.7% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
5.0%
3.1 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 1.9% · Q3 0.0% · Q4 1.3% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.4% |
75.7%
11.7 pts better
|
81.7%
5.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.1% · Q2 89.5% · 4Q avg 87.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.3% |
13.7%
10.6 pts worse
|
12.0%
12.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 23.7% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.6%
0.1 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 2.3% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.6% |
77.0%
6.6 pts better
|
79.7%
3.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.2% |
20.8%
0.4 pts worse
|
23.9%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.2% · Observed 19.6% · Expected 22.0% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
14 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Nutrition and Dietary (4 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Fire safety
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-09-18
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-10-15
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2025-10-06
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 2025-10-17
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-11-26
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-10-26
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-10-09
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-10-06
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 2025-10-02
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-10-26
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-26
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-10-26
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-18
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-10-16
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-08-07
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-17
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-17
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-03-09
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-03-09
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-03-08
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-03-08
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-03-16
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 2023-03-17
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-17
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-03-15
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-09
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-03-22
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-15
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-03-15
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-03-29
Fire Safety
Meet other general requirements.
Corrected 2023-03-08
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-10-16
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-10-02
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-16
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-10-01
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-08
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-08
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-21
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-01-13
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-13
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-13
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-18
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-17
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-06-17
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-17
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-06-17
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 2024-06-17
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-06-17
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-17
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-17
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-06-17
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-17
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-17
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-06-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-17
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 2024-06-17
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-17
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-15
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-11-06
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 2023-11-06
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2023-11-06
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-11-06
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-11-06
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-04-23
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-23
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-04-23
Penalties and ownership
Fine · fine $14,505
Fine
Fine · fine $14,508
Fine
Fine · fine $78,566
Fine
Fine · fine $8,018
Fine
Corporate Officer · Individual
W-2 Managing Employee · Individual
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