Niobrara County Hospital District
A critical access hospital in Lusk, Wyoming 82225
921 South Ballancee Avenue, Lusk, Wyoming 82225. (307) 334-4000.
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The short answer
Record last released by CMS on Oct 20, 2026.
- Not rated CMS’s overall rating
- Not rated patient survey rating
- 2 deficiencies cited in the last three years
- 24 beds
Each figure’s source sits beside it, in its section below.
What these words mean2
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Nov 19, 2025: a complaint inspection.
2 deficiencies cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
2 deficiencies in 1 month of the last 36. Last cited Nov 2025. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Nov 19, 2025: complaint inspection2 deficiencies
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Patient Care Policies
The inspectors’ words, 269 words
“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 37603 Based on medical record review, staff interview, and policy review, the facility failed to ensure a physician was notified when a patient was admitted by a mid-level practitioner for 1 of 4 sample patient records (#1). The findings were: 1. Review of the medical record for patient #1 showed on 11/15/25 “...HPI [History of Present Illness] [patient name] is being admitted to the hospital from the emergency department for several days of weakness, decreased appetitie, fatigue and malaise. Results from the emergency department shows a mild acute kidney injury secondary to dehydration, lactic acidosis, and leukopenia. [S/he] is being admitted to the hispital for IV hydration and resolution leevated lactate. CT of the chest abdomen pelvis is not acute...” The order was placed by PA #2. Further, review failed to show a physician was notified. The patient was admitted to inpatient (medical/surgical). 2. Review of the policy “Extended Care Facility (ECF) Admission Procedure” had delivered on 11/18/25 at 1:10 PM by HR showed “...2. c. The physical admission orders and note MUST be done by an MD or credentialed ER provider in the EMR system under the (ECF) tab no later than 24 hours after admission...” No inpatient admission policy was provided. 3. Interview with HR #1 on 11/18/25 at 2:15 PM confirmed the admission documentation was only signed by the PA and there was no evidence the physician had been notified of the admission.”
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Nursing Services
The inspectors’ words, 601 words
“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 37603 Based on medical record review, patient and patient representative interview, staff interview, and policy review, the facility failed to ensure patient care was provided according the patient’s needs for 1 of 20 patients reviewed (#17). The findings were: 1. Review of the medical record for patient #17 showed the patient had diagnoses including diabetes mellitus,depressive disorder, anemia, history of hip fracture, and chronic renal insufficiency. Review of the 8/27/25 at 12:05 AM notes showed “...HPI [History of Present Illness] right lower leg laceration. Again [s/he] was found on the floor in [his/her] room. [S/he] is not sure what happened but [s/he] thinks [s/he] caught [his/her] right leg against [his/her] walker. [S/he] has a large laceration to the right lower extremity. [S/he] also has right wrist and right shoulder pain. [S/he]denies loss of consciousness and is alert and oriented.” The following concern were identified: a. Review of the September 2025 Medication Administration Record (MAR) / Treatment Administration Record (TAR) showed an order for “Right lower leg dressing changes as needed, dated 8/26/25. Further, review showed only 1 removal of dressing on 9/10/25. There was no dressing change or other removal noted for the month of September. Review of the order “Change dressings everyday and as needed if soiled. can remove in shower.” showed it was started on 9/15/25. Review of the medical record showed on 9/22/25 and 9/23/25 the task was not completed. 2. Interview with LPN #1 on 11/18/25 at 8:25 AM revealed the nurse would initial the order when the care was completed in the MAR/TAR. Further, they revealed if something was not done the line would be left blank. 3. Interview on 11/17/25 at 8:10 AM with the patient representative revealed the wound on the right lower leg happened on 8/25/25. The patient fell in the facility. They stated the leg became necrotic, and they [the facility] left it open. The patient saw his/her provider on 9/26/24 and the wound was debrided, due to how necrotic it was. The wound care team started taking over care. 4. Interview with patient #17 on 11/18/25 at 8:38 AM revealed s/he had his/her walker, was coming out of the bathroom and fell. S/he stated a wire from the walker cut the right lower leg. S/he stated the Emergency Department stitched up the leg. S/he stated the nurses were not taking care of him/her like they were suppose to. The patient stated the wound got bad. 5. Interview with PA #1 and RN #2 on 11/19/25 at 10:45 AM revealed the patient came in for a follow-up on 9/26/25 on the wrist. The patient stated his/her leg was bothering them. S/he had a fall in August and had 17 sutures. They assessed the wound, and debrided at that time. The patient now has wound care services. 6. Review of the policy “Wound Assessment and Management” had delivered on 11/18/25 at 1:10 PM showed “...3. Wounds must be assessed for possible infection every time the dressing is change...If a wound is suspected to be infected the physician who has assumed care of the patient must be notified immediately for intervention...5. General skin checks will be done daily by nursing staff and documented as such...””
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Nov 19, 2025 | Complaint inspection | 2 deficiencies cited |
How do patients fare?
- CMS gives no overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.: “There are too few measures or measure groups reported to calculate a star rating or measure group score.”
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 1; readmission, 0 better and 0 worse of 1.
- CMS gives no CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.: “The number of cases/patients is too few to report a star rating.”
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): pneumonia 17.7%. CMS gives no comparison with the national rate for them in this release.
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | Not rated |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | Not rated |
Is it certified, and in good standing?
- Medicare-certified critical access hospital since Aug 15, 2005.
- Ownership: government - hospital district or authority.
- It is not accredited by a private organisation, so the state carries out its routine inspections for Medicare.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- Government - Hospital District or Authority.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- CMS’s HAC Reduction Program file has no result for it: the program covers general acute care hospitals Medicare pays under its inpatient prospective payment system.
- 2 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- 4 owners or officers are people: Dana Gilleland (runs it (operational or managerial control), 100%); John Vincent Boldon (corporate director); Travis Krein (corporate director); Randi Ross (corporate director).
- CMS’s Provider of Services file records no change of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
How does it compare nearby?
- No other hospital CMS lists is in Niobrara County.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.