Cycle 1
Health 2024-07-11 · Fire 2024-07-11
6 health deficiencies
Top issue: Administration (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Newcastle, WY
Weston County Health Services
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
1124 Washington Blvd, Newcastle, WY
(307) 746-2793
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
58
Certified beds
Average residents
53
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1984-09-04
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
0.55
Registered nurse staffing · state 0.90 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.48 · national 0.87
Aide hours / resident day
2.35
Nurse aide staffing · state 2.46 · national 2.35
Total nurse hours
3.53
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.18
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.01
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
0.00
Reported PT staffing
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
4.22
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
52%
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 | 5.83% |
8.2%
2.4 pts worse
|
Numerator 6 · Denominator 103 |
| Staff flu vaccination coverage | 67.46% |
42%
25.5 pts better
|
Numerator 85 · Denominator 126 |
| 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 | 1.1 |
1.3
0.2 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.2
0.6 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
94.3%
4 pts better
|
93.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.7% · Q4 96.0% · 4Q avg 98.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.3%
5.7 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
4.8%
0.4 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 0.0% · Q3 4.5% · Q4 6.0% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.4%
6.4 pts better
|
11.4%
11.4 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 who lose too much weight | 2.4% |
6.5%
4.1 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 2.8% · Q3 2.3% · Q4 0.0% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.7% |
16.1%
8.4 pts better
|
19.6%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 8.3% · Q3 7.0% · Q4 8.0% · 4Q avg 7.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.5% |
24.1%
1.4 pts worse
|
16.7%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 31.2% · Q3 25.0% · Q4 20.9% · 4Q avg 25.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 2.3% |
0.1%
2.2 pts worse
|
0.1%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.6% · Q3 2.3% · Q4 2.0% · 4Q avg 2.3% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.6% |
18.5%
4.9 pts better
|
16.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 16.1% · Q3 14.0% · Q4 12.2% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.9% |
18.7%
1.2 pts worse
|
14.9%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 24.2% · Q3 20.5% · Q4 18.8% · 4Q avg 19.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.9%
1.9 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
3.0%
0.5 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 6.8% · Q4 4.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.9% |
23.6%
3.7 pts better
|
19.8%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.2% · Q2 18.3% · Q3 15.4% · Q4 16.7% · 4Q avg 19.9% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
5.0%
3.1 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.4% · Q3 3.4% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.8% |
75.7%
12.1 pts better
|
81.7%
6.1 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 87.8% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-13 · Fire 2023-04-13
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2022-03-10 · Fire 2022-03-10
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-11
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-11
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-11
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2024-09-04
F · Potential for more than minimal harm
2023-04-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-01
E · Potential for more than minimal harm
2023-04-13
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-04-13
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 2023-05-01
D · Potential for more than minimal harm
2023-04-13
K255 · Egress Deficiencies
Fire Safety
Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-04-13
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-05-16
D · Potential for more than minimal harm
2023-04-13
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-04-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-01
F · Potential for more than minimal harm
2022-03-10
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-04-28
F · Potential for more than minimal harm
2022-03-10
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-05-16
F · Potential for more than minimal harm
2022-03-10
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-05-16
E · Potential for more than minimal harm
2022-03-10
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 2022-04-28
E · Potential for more than minimal harm
2022-03-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-04-28
E · Potential for more than minimal harm
2022-03-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-03-10
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-03-10
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-04-28
Inspection history
Recent health citations
G · Actual harm
2025-12-11
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 2026-01-05
E · Potential for more than minimal harm
2025-12-11
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 2026-01-05
F · Potential for more than minimal harm
2024-07-11
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2024-08-25
F · Potential for more than minimal harm
2024-07-11
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 2024-08-25
F · Potential for more than minimal harm
2024-07-11
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-07-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-25
E · Potential for more than minimal harm
2023-04-13
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2023-05-01
E · Potential for more than minimal harm
2023-04-13
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 2023-05-01
D · Potential for more than minimal harm
2023-04-13
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 2023-05-01
D · Potential for more than minimal harm
2023-04-13
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 2023-05-01
D · Potential for more than minimal harm
2023-04-13
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 2023-05-01
D · Potential for more than minimal harm
2023-04-13
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 2023-05-01
D · Potential for more than minimal harm
2023-04-13
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 2023-05-01
D · Potential for more than minimal harm
2023-04-13
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-04-13
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 2023-05-01
C · Minimal harm
2023-04-13
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-05-01
E · Potential for more than minimal harm
2022-03-10
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2022-03-31
Penalties and ownership
What sits behind the stars
Ownership
Weston County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Cadwell, Maureen
Corporate Director · Individual
Cadwell, Maureen
Corporate Officer · Individual
Cadwell, Maureen
W-2 Managing Employee · Individual
James, Connie
Corporate Officer · Individual
Materi, Georgenna
Corporate Officer · Individual
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