Cycle 1
Health 2025-11-20 · Fire 2025-11-20
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Thermopolis, WY
Thermopolis Rehabilitation and Wellness
2-star overall rating with 2-star inspections with $27,072 in total fines with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1210 Canyon Hills Rd, Thermopolis, WY
(307) 864-5591
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
34
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Evergreen Healthcare Group
Operator or chain grouping
Approved since
1994-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
41 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 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
Hours and turnover
RN hours / resident day
0.79
Registered nurse staffing · state 0.90 · national 0.68
LPN hours / resident day
0.51
Licensed practical nurse staffing · state 0.48 · national 0.87
Aide hours / resident day
2.68
Nurse aide staffing · state 2.46 · national 2.35
Total nurse hours
3.97
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.75
Weekend nurse staffing · state 3.30 · national 3.43
Weekend RN hours
0.66
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
0.87
CMS adjusted RN staffing hours
Adjusted total hours
4.36
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 53% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,022
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
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
0
Baseline 5.92% · Performance 7.79% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 70.00% · Performance 84.61% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
4.29
Baseline 3.85 hours · Performance 4.30 hours · Measure score 4.29 · Achievement 4.29 · Improvement 1.82
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.06% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 46 · Observed rate 6.52% · Lower 95% interval 6.6% |
| Discharge to community | 34.27% |
50.57%
16.3 pts worse
|
Worse than the National Rate · Eligible stays 49 · Observed rate 24.49% · Lower 95% interval 25.04% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 78.95% |
95.27%
16.3 pts worse
|
Numerator 30 · Denominator 38 |
| Falls with major injury | 5.26% |
0.77%
4.5 pts worse
|
Numerator 2 · Denominator 38 |
| Discharge self-care score | 31.03% |
53.69%
22.7 pts worse
|
Numerator 9 · Denominator 29 |
| Discharge mobility score | 41.38% |
50.94%
9.6 pts worse
|
Numerator 12 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 37 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.79% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 9.68% · Lower 95% interval 4.54% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 65 |
| Staff flu vaccination coverage | 71.43% |
42%
29.4 pts better
|
Numerator 25 · Denominator 35 |
| Discharge function score | 44.83% |
56.45%
11.6 pts worse
|
Numerator 13 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 22.22% |
25.2%
3 pts worse
|
Numerator 6 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.3
0.1 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.7 · Used in QM five-star |
| 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 · Adjusted 1.5 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 7.1% |
4.8%
2.3 pts worse
|
3.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 9.1% · Q3 2.9% · Q4 3.3% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.1% |
6.4%
1.3 pts better
|
11.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 6.5% · Q3 6.1% · Q4 0.0% · 4Q avg 5.1% |
| Percentage of long-stay residents who lose too much weight | 8.1% |
6.5%
1.6 pts worse
|
5.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 6.2% · Q3 9.4% · Q4 10.0% · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.6% |
16.1%
6.5 pts worse
|
19.6%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 21.2% · Q3 18.8% · Q4 23.3% · 4Q avg 22.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.0% |
24.1%
4.1 pts better
|
16.7%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 28.0% · Q3 10.0% · Q4 9.5% · 4Q avg 20.0% · 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 | 39.8% |
18.5%
21.3 pts worse
|
16.3%
23.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 69.1% · Q2 29.2% · Q3 33.4% · 4Q avg 39.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 33.1% |
18.7%
14.4 pts worse
|
14.9%
18.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 45.2% · Q3 22.6% · Q4 14.3% · 4Q avg 33.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.9%
1.9 pts better
|
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% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.5% |
23.6%
8.9 pts worse
|
19.8%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 49.2% · Q2 24.7% · Q3 40.8% · Q4 15.7% · 4Q avg 32.5% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
5.0%
2.8 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 0.0% · Q3 3.7% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.1% |
75.7%
15.4 pts better
|
81.7%
9.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 82.1% · Q2 86.4% · Q3 100.0% · Q4 100.0% · 4Q avg 91.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
13.7%
2.8 pts better
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 10.7% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.6%
1.6 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.3% |
77.0%
0.3 pts better
|
79.7%
2.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.6% |
20.8%
3.2 pts better
|
23.9%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.6% · Observed 17.9% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-27 · Fire 2024-06-27
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-04-20 · Fire 2023-04-20
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-12-15
F · Potential for more than minimal harm
2025-11-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-12-15
E · Potential for more than minimal harm
2025-11-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-12-15
E · Potential for more than minimal harm
2025-11-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-12-15
E · Potential for more than minimal harm
2025-11-20
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2025-12-15
F · Potential for more than minimal harm
2024-06-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-31
F · Potential for more than minimal harm
2024-06-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-31
F · Potential for more than minimal harm
2024-06-27
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-07-31
F · Potential for more than minimal harm
2024-06-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-31
E · Potential for more than minimal harm
2024-06-27
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-07-31
F · Potential for more than minimal harm
2023-04-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-05-18
F · Potential for more than minimal harm
2023-04-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-23
F · Potential for more than minimal harm
2023-04-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-04-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-04-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-25
F · Potential for more than minimal harm
2023-04-20
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-05-19
F · Potential for more than minimal harm
2023-04-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-10
E · Potential for more than minimal harm
2023-04-20
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-05-31
E · Potential for more than minimal harm
2023-04-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-28
D · Potential for more than minimal harm
2025-11-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-11-28
D · Potential for more than minimal harm
2025-11-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-28
D · Potential for more than minimal harm
2025-10-23
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 2025-10-25
D · Potential for more than minimal harm
2025-10-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-25
D · Potential for more than minimal harm
2025-07-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-07-07
F776 · Administration Deficiencies
Health
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected 2025-07-09
D · Potential for more than minimal harm
2024-06-27
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-07-31
K · Immediate jeopardy
2024-03-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-01
G · Actual harm
2024-03-06
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 2024-04-01
G · Actual harm
2023-08-22
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 2023-09-13
D · Potential for more than minimal harm
2023-04-20
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-04-20
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-04-20
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 2023-05-31
D · Potential for more than minimal harm
2023-04-20
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 2023-05-31
G · Actual harm
2023-03-10
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 2023-03-30
D · Potential for more than minimal harm
2023-03-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-30
Penalties and ownership
What sits behind the stars
$17,761
2024-03-06
Fine
Fine · fine $17,761
Fine
$9,311
2023-08-22
Fine
Fine · fine $9,311
Fine
Ownership
Pacific Northwest SNF Operations Holdings (Wy) LLC
5% Or Greater Direct Ownership Interest · Organization
Ch Pacific Northwest Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Couve Financial Services LLC
Operational/Managerial Control · Organization
Couve Healthcare Consulting LLC
Operational/Managerial Control · Organization
Herzka, Yisroel
5% Or Greater Indirect Ownership Interest · Individual
Kness, Sothea
Operational/Managerial Control · Individual
Lowe, Leonor
Operational/Managerial Control · Individual
Pacific Northwest Opco Management LLC
Operational/Managerial Control · Organization
Pacific Northwest SNF Operations Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Perlman, Harold
Operational/Managerial Control · Individual
Prillaman, Milissa
Operational/Managerial Control · Individual
Spielman, Shimon
Operational/Managerial Control · Individual
Spielman, Shimon
Corporate Officer · Individual
Stannard, Andrea
Operational/Managerial Control · Individual
Thermopolis SNF Operations, LLC
Operational/Managerial Control · Organization
Weyer, Jason
Operational/Managerial Control · Individual
Witzcorp Global LLC
5% Or Greater Indirect Ownership Interest · Organization
Wyoming SNF Consulting LLC
Operational/Managerial Control · Organization
Yenowitz, Yitzchok
5% Or Greater Indirect Ownership Interest · Individual
Yenowitz, Yitzchok
Operational/Managerial Control · Individual
Yenowitz, Yitzchok
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Worland Health and Rehabilitation
Worland, WY
3-star overall rating with 4-star inspections with $7,168 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Wind River Rehabilitation and Wellness
Riverton, WY
2-star overall rating with 2-star inspections with $37,772 in total fines with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Wyoming Retirement Center
Basin, WY
2-star overall rating with 2-star inspections with abuse icon flag with $41,201 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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