Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crook County Medical Services District Long Term C during CMS and state inspections, most recent first.
The facility failed to ensure RN coverage for 8 consecutive hours per day, 7 days per week during the 1st quarter of FY 2025. PBJ staffing data and the staff schedule showed multiple days in which no RN was on duty for the required hours, and the DON confirmed the lack of RN coverage on the identified days.
A resident with CVA and moderate cognitive impairment had bilateral bed canes built into the bed frame, but the medical record had no evidence of a bedrail assessment, including entrapment risk. The DON confirmed a safety assessment should have been completed, and the resident said the bedrails were used for positioning.
The facility failed to maintain infection prevention practices during catheter care and assisted dining. An LPN was observed with a resident’s urinary catheter drainage bag placed on the floor without protection, despite the expectation that it be kept below the bladder and covered. In a separate dining observation, a CNA assisted two residents and moved between tasks, including feeding one resident and repositioning another, without performing hand hygiene between activities; the IP confirmed hand hygiene should occur between tasks.
A facility did not report the findings of an abuse investigation within the required timeframe. A resident reported an abuse allegation to the charge nurse, and the initial report was sent to the State Survey Agency three days later. However, the investigative findings were not reported over a month later. The DON confirmed the investigation had not been reported and was unaware of the reporting requirement.
A resident was physically assaulted by their roommate with a metal clip, resulting in a laceration and bruising that required ER treatment. The incident was witnessed by a CNA who intervened to prevent further harm. Concerns were raised about the appropriateness of rooming arrangements given the victim's disabilities, and the DON admitted to a lack of a performance improvement plan and documentation on managing the aggressor's behavior.
A facility failed to implement interventions for a resident with dementia, leading to concerning behaviors such as wandering, verbal aggression, and physical assault. The resident, with impaired cognitive skills and severe depression, refused personal care and meals. The facility lacked a behavior management policy and had not provided staff dementia care training for two years, contributing to the deficiency.
The facility failed to ensure a sanitary environment in the kitchen, with multiple deficiencies in monitoring and documenting the temperature and sanitizer concentration of the dishwashing machine, as well as the temperatures of the walk-in cooler, walk-in freezer, and reach-in cooler. Numerous instances of missing documentation and non-compliance with facility policies and the 2022 FDA Food Code were observed.
The facility failed to submit direct care staffing information on schedule for two of four quarterly periods. The PBJ review showed missing data for the 1st and 3rd quarters, which was confirmed by interviews with payroll management and the administrator.
The facility failed to ensure accurate MDS assessment information for a resident with atrial fibrillation who was administered Eliquis. The quarterly MDS assessments did not indicate the resident was receiving an anticoagulant during the 7-day look-back period, as confirmed by the ADON.
The facility failed to update the care plans for two residents to reflect their current needs. One resident's care plan was not revised to include comfort care measures despite progressing dementia and weight loss. Another resident's care plan did not include pain management goals and interventions, despite experiencing constant severe pain and being prescribed pain medications. These deficiencies were confirmed by the ADON.
A facility failed to follow proper infection prevention techniques during wound care for a resident. The RN involved was not wound care certified and admitted to fanning the wounds and using dirty outer packets during the clean process, contrary to professional standards and facility expectations.
The facility failed to include the facility's name on daily staff postings over a two-week period. The ADON was unaware of this requirement and confirmed the omission. The census was 20.
RN Coverage Not Maintained for Required Daily Hours
Penalty
Summary
The facility failed to ensure an RN was on duty for 8 consecutive hours per day, 7 days per week during 1 of 4 quarters reviewed, specifically the 1st quarter of fiscal year 2025. Review of the PBJ Staffing Data Report for October 1, 2024 through December 31, 2025 showed no RN on duty for 8 consecutive hours on 2 days in November 2024 and 5 days in December 2024. Review of the staff schedule for November and December 2024 confirmed there were no RNs on duty for 8 consecutive hours on those same days. The census was 27, and interview with the DON on 8/14/25 at 10:46 AM confirmed the facility did not have RN coverage 7 days a week for at least 8 consecutive hours a day on the identified days.
Failure to Complete Bed Rail Safety Assessment
Penalty
Summary
The facility failed to ensure a safety assessment, including entrapment risk, was completed for resident #21 before the use of bilateral bed canes built into the bed frame. The quarterly MDS showed the resident had diagnoses including cerebrovascular accident and a BIMS score of 8 out of 15, indicating moderate cognitive impairment. Observation showed the resident had bilateral bed canes, and the medical record contained no evidence that a bedrail assessment, including entrapment risks, had been completed. The DON confirmed there should have been a safety assessment for the bedrails. The resident stated that the bedrails were used for positioning. The facility policy on Proper use of Bed Rails stated that a nurse assigned to the resident will complete reassessments at least quarterly, upon a significant change in status, or when there is a change in the type of bed, mattress, or rail.
Infection Prevention and Control Lapses in Catheter Care and Dining Assistance
Penalty
Summary
The facility failed to maintain infection prevention practices during urinary catheter care for one resident. During an observation, two LPNs entered the resident’s room and the resident’s catheter drainage bag was positioned on the floor at the foot of the bed without a cover or other protection. When interviewed at that time, one LPN stated the facility expected the bag not to be on the floor and to be covered. The IP later confirmed the expectation was for the urinary catheter drainage bag to be positioned below the bladder and covered, and that the bag should not be placed on the floor because basins were available to prevent that placement. The facility also failed to maintain hand hygiene during assisted dining for one CNA and one resident. During a dining observation, the CNA assisted residents at the table, gave a bite of food to one resident, then turned to another resident, adjusted the footrests, placed the resident’s feet on the footrests, repositioned the resident in the wheelchair, and then returned to provide additional bites of food to the first resident without performing hand hygiene between tasks. The IP confirmed that hand hygiene should be performed between tasks. The facility’s policy stated that hand hygiene is the primary means of preventing the transmission of infection.
Failure to Timely Report Abuse Investigation Findings
Penalty
Summary
The facility failed to report the findings of an investigation into an allegation of staff-to-resident abuse within the required timeframe. A resident reported an abuse allegation to the charge nurse, and the initial report was sent to the State Survey Agency three days later. However, as of over a month later, there was no evidence that the facility's investigative findings had been reported. An interview with the director of nursing confirmed that the investigation had not been reported, and she was unaware of the requirement to report the investigation to the state survey agency.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. An incident occurred where one resident assaulted their roommate with the metal clip of a pair of suspenders, resulting in a 1-centimeter laceration on the victim's left cheek. The injured resident required treatment in the emergency room, where the wound was treated with steristrips, and bruising developed at the site. A Certified Nursing Assistant (CNA) witnessed the incident and had to intervene to prevent further assault. The CNA confirmed that the aggressor continued to swing the suspenders at the victim until restrained. The resident representative expressed concerns about the decision to place a roommate with the victim, who was blind, deaf, and unable to communicate, questioning the staff's judgment in this matter. The Director of Nursing (DON) acknowledged the lack of a performance improvement plan and mentioned ongoing efforts to develop a new system for reporting incidents and investigations. However, there was no documentation on how the staff monitored or managed the aggressive resident's behaviors, indicating a gap in the facility's response to the incident.
Failure to Address Dementia Care Needs
Penalty
Summary
The facility failed to develop and implement appropriate interventions for a resident diagnosed with dementia, leading to several concerning behaviors and incidents. The resident, who had moderately impaired cognitive skills and severe depression, exhibited behaviors such as inattention, disorganized thinking, and an inability to recall important details. Upon admission, the resident was disheveled, refused to shower, and was non-compliant with incontinence products. The resident also refused meals, consuming only specific items like ice cream bars and banana bread. Over the course of several days, the resident displayed wandering behaviors, entering other residents' rooms, and required frequent redirection. The resident's behavior escalated to verbal aggression, setting off alarms, and eventually physically assaulting a roommate, resulting in a laceration. Interviews with the Director of Nursing (DON) revealed that the facility lacked a formal policy on behavior management or dementia care, and there was no documentation of staff efforts to manage the resident's behaviors. Additionally, the facility had not provided staff education on dementia care for the past two years, with planned training sessions being postponed due to external events. This lack of structured intervention and staff training contributed to the facility's inability to adequately address the resident's dementia care needs, resulting in the observed deficiencies.
Sanitary Environment Deficiency in Kitchen
Penalty
Summary
The facility failed to ensure a sanitary environment in the kitchen, as evidenced by multiple deficiencies in monitoring and documenting the temperature and sanitizer concentration of the dishwashing machine, as well as the temperatures of the walk-in cooler, walk-in freezer, and reach-in cooler. Observations and reviews of log sheets revealed numerous instances where required documentation was missing, including 32 out of 93 opportunities in March 2024 and 23 out of 90 opportunities in April 2024 for the dishwashing machine. Additionally, the temperature logs for the walk-in cooler, walk-in freezer, and reach-in cooler showed several missing entries across multiple dates, and the expected temperature ranges were not posted on the log sheets as required by the facility's policies and the 2022 FDA Food Code. The dishwashing machine's wash and rinse water temperatures and chlorine sanitizer concentration were not consistently documented, with specific dates in March and April 2024 showing missing entries for breakfast, lunch, and dinner cycles. Similarly, the walk-in cooler and freezer temperature logs had numerous missing entries for both morning and afternoon shifts, and some recorded temperatures were outside the expected ranges. The reach-in cooler temperature logs for February and May 2024 also showed missing entries for both morning and afternoon shifts. Interviews with the administrator confirmed the incompleteness of the temperature log and dish machine sheets. The facility's policies for monitoring dishwasher and cooler/freezer temperatures were not adhered to, as evidenced by the missing documentation and lack of corrective actions for temperatures outside the specified ranges. The 2022 FDA Food Code emphasizes the importance of maintaining proper temperatures and sanitizer concentrations to ensure effective sanitization and prevent the spread of pathogens, which the facility failed to achieve.
Failure to Submit Direct Care Staffing Information on Schedule
Penalty
Summary
The facility failed to ensure direct care staffing information was submitted on schedule as specified by CMS for two of four quarterly periods. Specifically, the Payroll Base Journal (PBJ) review revealed that the facility did not submit data for the 1st quarter (10/2023-12/2023) and the 3rd quarter (4/2023-6/2023). Interviews with payroll management and the administrator confirmed that the deadlines for submission were missed for both quarters.
Inaccurate MDS Assessment for Anticoagulant Administration
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment information accurately reflected the resident's status for one of the twelve sampled residents. Specifically, for a resident with a diagnosis of atrial fibrillation who was administered 5 milligrams of Eliquis every 12 hours, the quarterly MDS assessments conducted on 12/6/23 and 3/6/24 did not indicate that the resident was receiving an anticoagulant during the 7-day look-back period. This discrepancy was confirmed during an interview with the Assistant Director of Nursing (ADON) on 5/9/24.
Failure to Revise Care Plans for Comfort Care and Pain Management
Penalty
Summary
The facility failed to ensure the comprehensive care plan was revised to reflect the current needs of two residents. For one resident with moderate dementia, heart failure, and depression, the care plan was not updated to include comfort care measures after a physician's note indicated the resident was placed on comfort care due to progressing dementia and weight loss. This was confirmed by the Assistant Director of Nursing (ADON) during an interview. For another resident experiencing constant pain at an intensity level of 10 out of 10, the care plan was not revised to include goals and interventions related to pain management. Despite the resident's pain being documented in multiple assessments and the resident being prescribed acetaminophen and tramadol, the care plan did not reflect these needs. This oversight was also confirmed by the ADON during an interview.
Infection Prevention Deficiency During Wound Care
Penalty
Summary
The facility failed to ensure proper infection prevention techniques during a wound care observation for a resident. During the procedure, the RN donned gloves, placed a barrier under the resident's legs, and set unopened supplies on the table. She removed the old dressing, cleaned the wound, and fanned the wound with a dressing packet before applying the new dressing. This process was repeated for both legs. The RN confirmed that she was not wound care certified and that she fanned the wounds because the resident liked it. She also acknowledged that the outer packets were dirty and were opened during the clean process. The ADON confirmed that the facility's expectation was for staff to keep clean procedures clean, change gloves between dirty and clean tasks, and not to fan wounds. A review of professional standards indicated that proper wound care involves performing hand hygiene, using clean barriers, and avoiding contamination by not using outer packets during the clean process. The RN's actions did not align with these standards, leading to a deficiency in infection prevention and control.
Failure to Include Facility Name on Daily Staff Postings
Penalty
Summary
The facility failed to ensure the data requirements were included on the daily staff postings. A review of two weeks of daily staff postings showed that the facility's name was not included. An interview with the Assistant Director of Nursing (ADON) revealed that she was unaware that the facility's name needed to be on the daily staff postings and confirmed that the facility name was not present on the postings. The census at the time was 20.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sundance
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spearfish Canyon Healthcare | 26.8 mi | ★★★★★ | 13 | 0 |
| Rolling Hills Healthcare | 31.5 mi | ★★★★★ | 12 | 0 |
| Weston County Health Services | 39.7 mi | ★★★★★ | 3 | 0 |
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