Cycle 1
Health 2024-11-15 · Fire 2024-11-15
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Douglas, WY
Summit Ridge Skilled Nursing & Rehabilitation
1-star overall rating with 2-star inspections with abuse icon flag with $34,646 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1108 Birch Street, Douglas, WY
(307) 358-3397
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
46
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-01-01
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
Hours and turnover
RN hours / resident day
0.74
Registered nurse staffing · state 0.90 · national 0.68
LPN hours / resident day
0.28
Licensed practical nurse staffing · state 0.48 · national 0.87
Aide hours / resident day
1.51
Nurse aide staffing · state 2.46 · national 2.35
Total nurse hours
2.53
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.02
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.06
Weekend nurse staffing · state 3.30 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.62 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
2.80
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
11,394
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.91
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
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
3.38
Baseline 7.64% · Performance 6.82% · Measure score 3.38 · Achievement 3.38 · Improvement 2.59
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0
Baseline 2.83 hours · Performance 2.86 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.03% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 10.87% · Lower 95% interval 6.67% |
| Discharge to community | 43.12% |
50.57%
7.5 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 36.11% · Lower 95% interval 30.38% |
| Medicare spending per beneficiary | 1.33 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 35 · Denominator 35 |
| Falls with major injury | 2.86% |
0.77%
2.1 pts worse
|
Numerator 1 · Denominator 35 |
| Discharge self-care score | 24% |
53.69%
29.7 pts worse
|
Numerator 6 · Denominator 25 |
| Discharge mobility score | 48% |
50.94%
2.9 pts worse
|
Numerator 12 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 2.86% |
2.29%
0.6 pts worse
|
Numerator 1 · Denominator 35 · Adjusted rate 2.6% |
| Healthcare-associated infections requiring hospitalization | 6.82% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 3.85% · Lower 95% interval 3.26% |
| Staff COVID-19 vaccination coverage | 3.66% |
8.2%
4.5 pts worse
|
Numerator 3 · Denominator 82 |
| Staff flu vaccination coverage | 30.77% |
42%
11.2 pts worse
|
Numerator 28 · Denominator 91 |
| Discharge function score | 48% |
56.45%
8.5 pts worse
|
Numerator 12 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.76% |
25.2%
20.4 pts worse
|
Numerator 1 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.3
0.3 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
2.2
1 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.4% |
94.3%
9.9 pts worse
|
93.4%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 84.6% · Q2 78.8% · Q3 89.2% · Q4 84.2% · 4Q avg 84.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 85.0% |
94.3%
9.3 pts worse
|
95.5%
10.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 85.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
4.8%
1.4 pts better
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.0% · Q3 2.7% · Q4 5.3% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.9% |
6.4%
2.5 pts better
|
11.4%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 2.9% · Q4 8.3% · 4Q avg 3.9% |
| Percentage of long-stay residents who lose too much weight | 0.7% |
6.5%
5.8 pts better
|
5.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.3% |
16.1%
2.8 pts better
|
19.6%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 13.3% · Q3 13.9% · Q4 11.8% · 4Q avg 13.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.2% |
24.1%
6.9 pts better
|
16.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 21.7% · Q3 21.4% · Q4 8.3% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 2.0% |
0.1%
1.9 pts worse
|
0.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 2.7% · Q4 2.6% · 4Q avg 2.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.6% |
18.5%
1.1 pts worse
|
16.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 19.7% · Q3 15.9% · Q4 22.6% · 4Q avg 19.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.1% |
18.7%
2.4 pts worse
|
14.9%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 23.3% · Q3 14.3% · Q4 27.3% · 4Q avg 21.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.8% |
1.9%
1.9 pts worse
|
1.0%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.5% · Q3 5.9% · Q4 3.1% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.5% |
3.0%
4.5 pts worse
|
1.7%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 9.1% · Q3 8.1% · Q4 2.6% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.6% |
23.6%
3 pts better
|
19.8%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 15.6% · Q3 24.9% · Q4 16.5% · 4Q avg 20.6% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
5.0%
0.3 pts worse
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 3.0% · Q3 9.5% · Q4 5.8% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 60.0% |
75.7%
15.7 pts worse
|
81.7%
21.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 60.9% · Q2 54.5% · Q3 69.0% · Q4 56.0% · 4Q avg 60.0% |
| 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 11.1% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.6%
About the same
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q3 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.8% |
77.0%
1.8 pts better
|
79.7%
0.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.2% |
20.8%
3.6 pts better
|
23.9%
6.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.2% · Observed 18.5% · Expected 25.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-30 · Fire 2023-08-30
11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
13 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2022-08-10 · Fire 2022-08-10
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-15
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 2024-12-20
D · Potential for more than minimal harm
2024-11-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-20
F · Potential for more than minimal harm
2023-08-30
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-10-16
F · Potential for more than minimal harm
2023-08-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-16
F · Potential for more than minimal harm
2023-08-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-16
E · Potential for more than minimal harm
2023-08-30
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 2023-10-16
E · Potential for more than minimal harm
2023-08-30
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 2023-10-16
E · Potential for more than minimal harm
2023-08-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-08-30
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 2023-10-16
D · Potential for more than minimal harm
2023-08-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-08-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-08-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-08-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-08-30
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-08-30
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-10-16
F · Potential for more than minimal harm
2022-08-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-15
F · Potential for more than minimal harm
2022-08-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-15
F · Potential for more than minimal harm
2022-08-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-10-11
F · Potential for more than minimal harm
2022-08-10
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-10-11
E · Potential for more than minimal harm
2022-08-10
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 2022-09-15
Inspection history
Recent health citations
G · Actual harm
2025-09-17
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 2025-10-10
D · Potential for more than minimal harm
2025-09-17
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-01-03
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-03
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 2024-12-20
D · Potential for more than minimal harm
2025-01-03
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 2025-02-14
G · Actual harm
2024-11-15
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-12-20
F · Potential for more than minimal harm
2024-11-15
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-12-20
F · Potential for more than minimal harm
2024-11-15
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-12-20
F · Potential for more than minimal harm
2024-11-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-15
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-15
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 2024-12-20
D · Potential for more than minimal harm
2024-11-15
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 2024-12-20
D · Potential for more than minimal harm
2024-11-15
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-12-20
E · Potential for more than minimal harm
2023-08-30
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 2023-10-16
D · Potential for more than minimal harm
2023-08-30
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-08-30
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-08-30
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-08-30
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-08-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-08-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-08-30
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-16
F · Potential for more than minimal harm
2022-08-10
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-09-15
D · Potential for more than minimal harm
2022-08-10
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 2022-09-15
D · Potential for more than minimal harm
2022-08-10
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2022-09-15
D · Potential for more than minimal harm
2022-08-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-09-15
D · Potential for more than minimal harm
2022-08-10
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 2022-09-15
Penalties and ownership
What sits behind the stars
$14,950
2025-09-17
Fine
Fine · fine $14,950
Fine
$19,696
2024-11-15
Fine
Fine · fine $19,696
Fine
Ownership
Health And Marketing West
5% Or Greater Direct Ownership Interest · Organization
Rude, Kathryn
5% Or Greater Direct Ownership Interest · Individual
Rude, Kathryn
Corporate Officer · Individual
Rude, Ramon
5% Or Greater Direct Ownership Interest · Individual
Rude, Ramon
Operational/Managerial Control · Individual
Rude, Ramon
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Casper Mountain Rehabilitation and Care Center
Casper, WY
1-star overall rating with 1-star inspections with Special Focus status with $116,051 in total fines with 30 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Life Care Center of Casper
Casper, WY
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Shepherd of the Valley Rehabilitation and Wellness
Casper, WY
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $78,536 in total fines with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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