Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Shepherd of the Valley Rehabilitation and Wellness
Casper, WY · 192 certified beds · Last Life Safety survey October 31, 2024
CMS Certification Number 535042 · first certified November 1990
Ownership
Operated by EVERGREEN HEALTHCARE GROUP · For profit - Corporation
- New ownershipOwnership changed September 30, 2025 (change of ownership)from SHEPHERD OF THE VALLEY SNF OPERATIONS, LLC
Position within WY
29 citations — more than 86% of the 36 certified nursing homes in WY. Compared within WY rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 5 citations; the earlier surveys in the window averaged 12. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Past the typical window (November 2025 to April 2026). Most US facilities have been surveyed by December 2026. This facility’s last Life Safety survey was October 2024. Nursing homes nationally are typically surveyed 12–17 months after the last one (median 14), measured over 19,385 consecutive surveys in the last two years of CMS records. WY has too few recent surveys to measure on its own, so the national interval is used.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 29 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
9 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 29 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in WY, and nationally. Surveyors differ markedly between states, so the WY figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 29 |
| Median facility in WY | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 31, 2022 | 16 |
| August 10, 2023 | 8 |
| October 31, 2024 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 3 | 2024-10-31 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-10-31 |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | 2 | 2023-08-10 |
| K-0222 | 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. | 2 | 2023-08-10 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 2 | 2024-10-31 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2024-10-31 |
| K-0351 | Install an approved automatic sprinkler system. | 2 | 2023-08-10 |
| K-0293 | Have properly located and lighted "Exit" signs. | 1 | 2023-08-10 |
What the citations cover
- Smoke Deficiencies 12
- Egress Deficiencies 7
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Miscellaneous Deficiencies 3
- Other 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 12 |
| Egress Deficiencies | 7 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Miscellaneous Deficiencies | 3 |
| Construction Deficiencies | 1 |
| Services Deficiencies | 1 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
October 31, 2024 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (December 6, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 6, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 6, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (December 6, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 6, 2024) |
August 10, 2023 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0100 | Meet other general requirements. | Deficient, Provider has date of correction (September 4, 2023) |
| K-0222 | 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. | Deficient, Provider has date of correction (September 4, 2023) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (September 4, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (September 4, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (September 4, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (September 4, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 4, 2023) |
| K-0906 | Ensure gas cylinders are properly stored. | Deficient, Provider has date of correction (September 4, 2023) |
August 31, 2022 — 16 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (October 7, 2022) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (October 7, 2022) |
| K-0222 | 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. | Deficient, Provider has date of correction (October 7, 2022) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (October 7, 2022) |
| K-0300 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (October 7, 2022) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 7, 2022) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 7, 2022) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (October 7, 2022) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (October 7, 2022) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (October 7, 2022) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (October 7, 2022) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (October 7, 2022) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (October 7, 2022) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (October 7, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 7, 2022) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (October 7, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.