Cycle 1
Health 2025-08-14 · Fire 2025-08-14
3 health deficiencies
Top issue: Infection Control (1 deficiency)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Sundance, WY
Crook County Medical Services District Long Term C
3-star overall rating with 3-star inspections with $8,824 in total fines with 3 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
713 Oak St, Sundance, WY
(307) 283-3501
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
32
Certified beds
Average residents
28
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1986-12-31
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.01
Registered nurse staffing · state 0.90 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.48 · national 0.87
Aide hours / resident day
3.21
Nurse aide staffing · state 2.46 · national 2.35
Total nurse hours
4.77
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.92
Weekend nurse staffing · state 3.30 · national 3.43
Weekend RN hours
0.68
Weekend registered nurse coverage · state 0.62 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.06
CMS adjusted RN staffing hours
Adjusted total hours
5.01
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
71%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
84%
Annual nurse turnover · state 53% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 31 |
| Staff flu vaccination coverage | 21.51% |
42%
20.5 pts worse
|
Numerator 20 · Denominator 93 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.3
0.3 pts worse
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.3 |
2.2
1.1 pts worse
|
1.8
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 3.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.8% |
94.3%
7.5 pts worse
|
93.4%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.0% · Q2 92.3% · Q3 82.8% · Q4 80.8% · 4Q avg 86.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 78.6% |
94.3%
15.7 pts worse
|
95.5%
16.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 78.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.9% |
4.8%
3.9 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.8% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.2% |
6.4%
3.2 pts better
|
11.4%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 4.0% · Q4 4.2% · 4Q avg 3.2% |
| Percentage of long-stay residents who lose too much weight | 22.9% |
6.5%
16.4 pts worse
|
5.4%
17.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.0% · Q2 24.0% · Q3 20.7% · Q4 15.4% · 4Q avg 22.9% |
| 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 20.0% · Q2 15.4% · Q3 13.8% · Q4 11.5% · 4Q avg 15.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.5% |
24.1%
9.6 pts better
|
16.7%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 9.5% · Q3 18.2% · Q4 14.3% · 4Q avg 14.5% · 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 | 15.8% |
18.5%
2.7 pts better
|
16.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.1% |
18.7%
7.4 pts worse
|
14.9%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 13.6% · Q3 33.3% · Q4 27.3% · 4Q avg 26.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
1.9%
0.3 pts better
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.3% · Q4 2.7% · 4Q avg 1.6% · 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 8.0% · Q2 7.7% · Q3 0.0% · Q4 7.7% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.2% |
23.6%
4.6 pts worse
|
19.8%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 29.1% · Q3 34.8% · Q4 29.7% · 4Q avg 28.2% |
| Percentage of long-stay residents with pressure ulcers | 14.1% |
5.0%
9.1 pts worse
|
5.1%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 22.1% · Q3 20.0% · Q4 8.5% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.1% |
75.7%
8.4 pts better
|
81.7%
2.4 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 84.1% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-09 · Fire 2024-05-09
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-02-16 · Fire 2023-02-16
13 health deficiencies
Top issue: Resident Rights (3 deficiencies)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-14
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-09-30
F · Potential for more than minimal harm
2025-08-14
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-09-30
F · Potential for more than minimal harm
2025-08-14
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-11-01
F · Potential for more than minimal harm
2025-08-14
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-10-15
E · Potential for more than minimal harm
2025-08-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-30
E · Potential for more than minimal harm
2025-08-14
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2025-09-22
E · Potential for more than minimal harm
2025-08-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-08-14
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-14
K222 · Egress Deficiencies
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 2025-10-15
D · Potential for more than minimal harm
2025-08-14
K223 · Egress Deficiencies
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 2025-10-10
D · Potential for more than minimal harm
2025-08-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-09-08
E · Potential for more than minimal harm
2024-05-09
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2024-07-30
D · Potential for more than minimal harm
2024-05-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-30
F · Potential for more than minimal harm
2023-02-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-04-15
E · Potential for more than minimal harm
2023-02-16
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-04-15
D · Potential for more than minimal harm
2023-02-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-15
D · Potential for more than minimal harm
2023-02-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-04-15
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-14
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-14
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-08-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-03
D · Potential for more than minimal harm
2024-11-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-31
G · Actual harm
2024-09-05
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 2024-10-31
D · Potential for more than minimal harm
2024-09-05
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-10-31
F · Potential for more than minimal harm
2024-05-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-03
F · Potential for more than minimal harm
2024-05-09
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-07-03
D · Potential for more than minimal harm
2024-05-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-03
D · Potential for more than minimal harm
2024-05-09
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-07-03
D · Potential for more than minimal harm
2024-05-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-03
B · Minimal harm
2024-05-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-07-03
F · Potential for more than minimal harm
2023-02-16
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-04-15
F · Potential for more than minimal harm
2023-02-16
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-04-15
E · Potential for more than minimal harm
2023-02-16
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 2023-04-15
E · Potential for more than minimal harm
2023-02-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-15
D · Potential for more than minimal harm
2023-02-16
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-04-15
D · Potential for more than minimal harm
2023-02-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-04-15
D · Potential for more than minimal harm
2023-02-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-15
D · Potential for more than minimal harm
2023-02-16
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 2023-04-15
D · Potential for more than minimal harm
2023-02-16
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-04-15
D · Potential for more than minimal harm
2023-02-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-15
D · Potential for more than minimal harm
2023-02-16
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 2023-04-15
C · Minimal harm
2023-02-16
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-04-15
C · Minimal harm
2023-02-16
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-04-15
Penalties and ownership
What sits behind the stars
$8,824
2024-09-05
Fine
Fine · fine $8,824
Fine
Ownership
Coleman, Sharon
Operational/Managerial Control · Individual
Edwards, Donna
Operational/Managerial Control · Individual
Fowler, William
Operational/Managerial Control · Individual
Hartl, Cody
Operational/Managerial Control · Individual
Hibbard, Robert
Operational/Managerial Control · Individual
Larsen, James
Operational/Managerial Control · Individual
Lyons, Micki
Operational/Managerial Control · Individual
Neiman, Sandra
Operational/Managerial Control · Individual
Sanderson-Zaato, Julie
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Spearfish Canyon Healthcare
Spearfish, SD
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Rolling Hills Healthcare
Belle Fourche, SD
1-star overall rating with 1-star inspections with $55,144 in total fines with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Weston County Health Services
Newcastle, WY
2-star overall rating with 2-star inspections with abuse icon flag with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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