Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Weston County Health Services during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and dementia had facility-managed trust funds used to purchase three Meta virtual reality headsets via Amazon. The corresponding debit was recorded in the trust account, but the devices were later found stored, largely unopened, in the activities room, with the activities director unaware of their ownership or use and unable to operate them. The resident’s representative was not informed of the purchase and believed the resident could not use such devices, while the NHA stated the items were bought as part of a Medicaid spend-down for the resident and possibly friends.
A resident with severe cognitive impairment and high assistance needs was physically abused by their roommate, who struck them in the head while the resident was seated in a wheelchair. Staff witnessed the incident, and the victim was found with redness on the head and later reported headaches. The two residents had a history of verbal conflict, but the facility failed to prevent the escalation to physical abuse, resulting in actual harm.
The facility did not provide enough nursing staff to meet resident needs, resulting in prolonged call light response times and inadequate care. A resident dependent on staff for transfers was left unable to reach the call light or phone, sometimes sitting in feces due to delays. Multiple residents and staff reported frequent understaffing, with some CNAs responsible for up to 27 residents at night and call lights going unanswered for over an hour. The DON confirmed there was no policy for call light response times and acknowledged ongoing staffing challenges.
The facility lacked a qualified administrator to manage operations and report to the governing body. Observations and interviews revealed the administrator was on leave for three months without a replacement, and was instructed not to enter the building, hindering effective management.
The facility did not submit mandatory staffing data to CMS for a specific quarter. An interview with the DON revealed that the data was not submitted in time, leading to a missed submission. A review of the PBJ confirmed the absence of data submission for the quarter.
The facility did not have a qualified administrator attending QAPI meetings, as the administrator was on leave and not allowed to enter the building. The position remained vacant, and no delegated administrator was in place, as confirmed by the CEO and DON.
A facility failed to ensure proper hand hygiene during a wound care procedure. An LPN did not perform hand hygiene after removing gloves and before donning a new pair, contrary to the facility's policy. This occurred during a dressing change for a resident, where initial hand hygiene was performed, but not maintained throughout the procedure.
Misappropriation of Resident Trust Funds for Unused Virtual Reality Devices
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when items were purchased with the resident’s trust account funds and not used for the resident’s benefit. The resident had severe cognitive impairment, with a BIMS score of 3/15 and diagnoses including dementia, non‑traumatic brain dysfunction, and Meniere’s disease, and the facility managed the resident’s funds through a trust account. Documentation showed that an Amazon order was placed for this resident that included three Meta virtual reality headsets at $399.99 each, and the resident’s trust account transaction history reflected a corresponding debit of $1,878.78 for Amazon purchases. Attempts to interview the resident were unsuccessful due to cognitive debilities. Surveyor observation found three Meta virtual reality headsets in their original boxes, one opened, stored in the activities storage room near the main dining room. The activities director stated she did not know who the devices belonged to, that they had been stored in the closet since February of the prior year, that the devices required internet access, and that she did not know how to use them. The resident’s responsible party reported having no knowledge of the Meta purchase and did not believe the resident would have been capable of operating the devices. The NHA stated that the resident was obligated to spend down the trust account as a Medicaid requirement and that three Meta virtual reality headsets were ordered for the resident and possibly some friends to use.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A resident with severe cognitive impairment and multiple diagnoses, including non-traumatic brain dysfunction and dementia, was subjected to physical abuse by their roommate. The resident required substantial to maximal assistance for mobility and had recently returned to the facility after being away for a few days. The incident occurred when another resident entered the room and was observed by staff hitting the resident in the head while the victim was seated in a wheelchair. The assaulted resident was found to have redness on the head and later complained of intermittent headaches following the incident. Staff interviews and medical record reviews confirmed that the two residents had a history of bickering, but there was no clear indication of what provoked the physical altercation. The staff member who witnessed the event reported hearing yelling and seeing the aggressor striking the resident, while the victim did not verbally respond during the incident. The nurse who assessed the situation noted mild redness to the back of the resident's head and documented that the resident expressed feeling unsafe with the aggressor as a roommate. The facility's policy states that residents will be protected from abuse, neglect, and harm while residing at the facility. Despite this, the resident was not protected from physical abuse by another resident, resulting in actual physical harm. The incident was witnessed by staff, and documentation indicated that the resident felt unsafe following the event.
Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents on three of four units, as evidenced by multiple interviews, grievance and call light log reviews, and direct observations. One resident, who was cognitively intact and dependent for toilet transfers, reported long wait times for call light responses and meals. The resident's representative and roommate confirmed that the resident was sometimes left sitting in feces due to extended wait times, and that the call light and phone were often placed out of reach. Observations confirmed the resident was left unable to access the call light and phone, and grievance logs documented similar concerns from the resident's family. Call light logs showed multiple instances of excessive wait times, including waits of up to 84 minutes. Additional interviews with residents during a council meeting revealed that call lights were often turned off by staff with promises to return, but assistance was not provided in a timely manner. One resident reported waiting 73 minutes for a call light to be answered. Staff interviews confirmed frequent understaffing, with reports of only one CNA on a locked unit and two for the rest of the building at times, resulting in residents being left soaked in the morning. CNAs described situations where one CNA was responsible for up to 27 residents at night, and call lights remained unanswered for over an hour. The DON acknowledged the lack of a facility policy on call light response times and confirmed ongoing issues with staffing and call light response.
Absence of Qualified Administrator in Facility
Penalty
Summary
The facility failed to ensure a qualified administrator was managing the facility and reporting to the governing body. Observations during the survey revealed that the nursing home administrator position was vacant, and no administrator was present in the facility. The QAPI committee attendance records for May and June showed the absence of the administrator. Interviews with the CEO and DON confirmed that the administrator had been on leave for three months without a delegated replacement. The administrator on leave stated she was instructed not to enter the building, making it impossible for her to manage the facility effectively.
Failure to Submit Staffing Data to CMS
Penalty
Summary
The facility failed to submit mandatory staffing data to CMS for the quarter from October 1, 2023, through December 31, 2023. This deficiency was identified during a staff interview with the Director of Nursing (DON) on July 10, 2024, at 4:32 PM, where it was revealed that the staffing data was not submitted in time, resulting in a missed submission. A review of the Payroll Based Journal (PBJ) confirmed that the facility did not submit the required data for the specified quarter.
Absence of Administrator in QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAPI) committee included a qualified administrator who attended meetings. Observations during the survey revealed that the nursing home administrator position was vacant, and no administrator was present in the facility. A review of the QAPI committee attendance sheets for May and June 2024 showed the absence of the administrator. Interviews with the CEO and the Director of Nursing (DON) confirmed that the administrator had been on leave for three months, and there was no delegated administrator in place. The administrator on leave stated that she was put on leave by the former CEO and was instructed not to enter the building, making it impossible for her to manage the facility effectively.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control during a wound care procedure for a resident. During an observation, two LPNs were involved in changing the dressing of a resident's wound. They performed initial hand hygiene and donned gloves and gowns. However, after removing the old dressing and cleaning the wound, one of the LPNs did not perform hand hygiene before donning a new pair of gloves, which she had moved earlier. This action was contrary to the facility's policy, which requires hand hygiene after removing gloves and before donning new ones. The LPN admitted that using hand sanitizer between dirty and clean tasks was not part of her routine, although it was expected by the facility's standards.
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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 Newcastle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Custer Care And Rehab Center | 30.4 mi | — | 38 | 0 |
| Crook County Medical Services District Long Term C | 39.7 mi | ★★★★★ | 0 | 0 |
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