Inspection Reports for Avamere at Cheyenne

The inspection was conducted as a result of a complaint investigation regarding call pendant response times at the facility.

The facility failed to ensure call pendants were answered in a timely manner, with documented response times frequently exceeding the facility's expected four-minute response time, including multiple instances of response times over 30 minutes.

One complaint was investigated (Complaint # NV00074837) and substantiated. The complaint involved delayed response times to resident call pendants, with residents reporting response times ranging from 12 to 60 minutes and documented evidence of multiple extended response times.

The inspection was conducted as a result of a complaint investigation at the facility on 07/07/25, in accordance with Nevada Administrative Code (NAC), Chapter 449, Residential Facility for Groups.

The investigation found no regulatory deficiencies. The complaint was unsubstantiated after review of resident grooming, staff interactions, call bell response, laundry facilities, interviews, and clinical record review.

One complaint (NV00073448) was investigated and found to be unsubstantiated. No regulatory deficiencies were identified.

This inspection was a mandatory State Licensure grading resurvey conducted as part of the facility's license renewal process in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.

The facility was found to be in compliance with no regulatory deficiencies identified. The facility received a grade of A, and no further action was necessary.

The inspection was conducted as an annual State Licensure survey combined with a complaint investigation at the facility on 02/11/2025.

The facility was found deficient in multiple areas including failure to ensure timely elder abuse training for employees, missing pre-employment physical exams, unsafe water temperatures, delayed call bell response times, incomplete first aid and CPR training, lack of updated medication agreements, improper placement of a resident with dementia, and missing Alzheimer's training for some employees.

Two complaints were investigated: Complaint #NV00072310 was substantiated related to resident placement and care; Complaint #NV00072745 was substantiated related to call bell response times.

The inspection was conducted as a combined annual and complaint State Licensure survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.

The facility was found to have several regulatory deficiencies including retaining a resident with an open wound without a medical exemption, failure to ensure an annual physical examination for one resident, and failure to obtain annual or initial placement assessments for multiple residents. One complaint was investigated and found unsubstantiated.

One complaint (Complaint #NV00070352) was investigated and found to be unsubstantiated.

This inspection was a State Licensure voluntary grading resurvey conducted at the facility on 05/15/23 in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.

The facility was licensed for 150 beds and had a census of 53 at the time of the survey. Three resident files were reviewed. The facility received a grade of A with no regulatory deficiencies identified and no further action necessary.

The inspection was conducted as an annual State Licensure and infection control survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facilities for Groups.

The facility was found to have multiple deficiencies including water temperatures exceeding acceptable ranges, food service violations, medication administration errors, failure to secure protected health information, and lack of a posted non-discrimination statement. Corrective actions and monitoring plans were outlined for each deficiency.

This inspection was a grading resurvey conducted at the facility on 08/23/22 in accordance with Nevada Administrative Code, Chapter 449, Residential Facilities for Groups.

The facility was reviewed for compliance with regulations including medical care, medication administration, storage, Alzheimer's care standards, and dementia care training. No regulatory deficiencies were identified and the facility received a new grade of A.

The inspection was conducted as a State Licensure Complaint Investigation survey initiated on 07/14/22 and concluded on 08/23/22, triggered by a complaint (#NV00066648) with five allegations regarding facility conditions and compliance.

The investigation substantiated one allegation that the facility did not have a current licensed Administrator as required by Nevada regulations. Four other allegations related to air conditioning, COVID and TB testing, medication administration, and physical examinations were unsubstantiated based on observations, interviews, and record reviews.

Complaint #NV00066648 with five allegations was investigated. One allegation regarding lack of a licensed Administrator was substantiated. The other four allegations about air conditioning, COVID/TB testing, medication administration, and physical exams were unsubstantiated.

The inspection was conducted as an annual State Licensure survey, infection control survey, and complaint investigation.

The facility received a grade of D with multiple deficiencies including food service violations, failure to notify responsible parties of resident condition changes, medication administration errors, unsecured medications and tools, lack of proper training for employees, and inadequate safety alarms on doors.

Complaint #NV00066074 was substantiated with three allegations: 1) Resident admitted to hospital with dehydration, blood clot, UTI, and malnourishment; 2) Responsible party not notified of resident's change in condition; 3) Family visitation restricted due to COVID-19 outbreak, substantiated without deficiencies.