Shepherd of the Valley: Call Light Left Out of Reach - WY
The resident didn't know where the call light was. When asked, they said only, "It should be around here somewhere."
Inspectors from the Centers for Medicare and Medicaid Services visited the facility on January 28, 2026, following a complaint. What they found was straightforward and repeated: the resident was seated in a recliner at the foot of the bed at 9:55 in the morning, and the call light was at the head of the bed. Forty minutes later, at 10:35, nothing had changed. The call light was still at the head of the bed. Still not within reach.
The resident's care plan, last revised in November 2025, listed a fall risk tied to confusion, gait and balance problems, and psychoactive drug use. A separate intervention, in place since November 2024, directed staff to ensure the call light stayed within reach at all times. The resident also scored a 16 out of 23 on a skin breakdown risk assessment, placing them in the at-risk category.
None of that translated into the call light being where it needed to be.
At 11:28 that morning, inspectors interviewed the resident, who confirmed they didn't know where the call light was. Five minutes later, the resident's representative was also present and confirmed the brief was wet, that the resident had no pants on beneath the blanket, and that the call light had not been accessible to request help.
The call light was eventually activated at 11:48, not by the resident, but by a guest who was visiting. A certified nursing assistant answered at 11:53, closed the door, left the room, came back with a clean blanket, and walked out at 12:04 carrying two bags of soiled linens.
That's just over an hour from the first observation to a response, for a resident who could not have summoned help on their own.
The director of nursing, interviewed the following evening, said the expectation was clear: when staff left a resident alone in their room, they were to make sure the resident had the call light and any other needs within reach before leaving. That expectation existed. Staff simply had not followed it, twice, in the same morning, for the same resident.
The nursing home administrator, interviewed at 7:15 PM on January 29, confirmed something else: the facility had no policy on call light use.
Not an outdated policy. Not a policy under revision. No policy at all.
The resident at the center of this inspection had moderately impaired cognition, scoring a 12 out of 15 on a standard cognitive assessment. They carried diagnoses of non-Alzheimer's dementia, depression, and cancer. They were, by the facility's own documentation, someone who could not reliably orient themselves to their environment or advocate for their own needs without assistance.
The inspection classified the harm level as minimal, meaning inspectors found no evidence of serious injury resulting from what happened that morning. That classification reflects what was documented, not what could have happened if the guest had not been there to press the call button.
The resident sat in a wet brief, covered by a blanket, without pants, for an unknown stretch of time before that visit. The facility had no written standard to prevent it from happening again.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Shepherd of the Valley Rehabilitation and Wellness from 2026-01-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Shepherd of the Valley Rehabilitation and Wellness in Casper, WY was cited for violations during a health inspection on January 29, 2026.
The resident didn't know where the call light was.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.