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🔎 Weston County Health Services

Inspection Results


Inspection Overview

Weston County Health Services has been cited for a total of 31 deficiencies since we began saving each survey.

In Wyoming, the average facility has **29.63 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: F

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.

Survey Date: 2024-07-11
Correction Date: 2024-08-25
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Survey Date: 2024-07-11
Correction Date: 2024-08-25
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Survey Date: 2024-07-11
Correction Date: 2024-08-25
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2024-07-11
Correction Date: 2024-08-25
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Survey Date: 2023-04-13
Correction Date: 2023-05-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2023-04-13
Correction Date: 2023-05-01
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2023-04-13
Correction Date: 2023-05-01
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2023-04-13
Correction Date: 2023-05-01
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2023-04-13
Correction Date: 2023-05-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure the activities program is directed by a qualified professional.

Survey Date: 2023-04-13
Correction Date: 2023-05-01
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2023-04-13
Correction Date: 2023-05-01
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2023-04-13
Correction Date: 2023-05-01
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2023-04-13
Correction Date: 2023-05-01
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: C

Ensure staff are vaccinated for COVID-19

Survey Date: 2023-04-13
Correction Date: 2023-05-01
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2022-06-16
Correction Date: 2022-07-15
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey Date: 2022-06-16
Correction Date: 2022-07-15
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Survey Date: 2022-03-10
Correction Date: 2022-03-31
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Assess the resident when there is a significant change in condition

Survey Date: 2021-03-11
Correction Date: 2021-04-09
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2021-03-11
Correction Date: 2021-04-09
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2021-03-11
Correction Date: 2021-04-09
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey Date: 2021-03-11
Correction Date: 2021-04-09
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2021-03-11
Correction Date: 2021-04-09
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2021-03-11
Correction Date: 2021-04-09
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-07-02
Correction Date: 2020-07-24
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2020-03-05
Correction Date: 2020-07-31
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2020-03-05
Correction Date: 2020-07-31
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2020-03-05
Correction Date: 2020-07-31
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2020-03-05
Correction Date: 2020-07-31
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Survey Date: 2020-03-05
Correction Date: 2020-07-31
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2020-03-05
Correction Date: 2020-07-31
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2020-03-05
Correction Date: 2020-07-31
Category: Infection Control Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**