Inspection Reports for
Cheyenne County Village, Inc

The facility failed to ensure the most recent survey report and plan of correction were available in a public area. The operator did not complete an initial negotiated service agreement for a resident and failed to review and revise the agreement annually. The facility also failed to file and pay annual renewal licensing fees for 2023, 2024, and 2025 and did not post the current license conspicuously.

The facility identified deficiencies related to hospice care planning, catheter care, medication labeling, food storage and sanitation, and infection control practices. Corrective actions include staff education, audits, and monitoring to ensure compliance.

The facility had multiple deficiencies including failure to revise care plans for hospice residents, improper catheter care leading to infection risk, failure to label and store drugs and biologicals properly, unsanitary food storage and preparation practices, and inadequate infection prevention and control practices.

The facility failed to complete annual functional capacity screenings for residents, lacked complete negotiated service agreements including responsible parties for payment and licensed nurse identification, improperly stored medications, and failed to comply with tuberculosis screening guidelines for residents and staff.

The complaint investigation focused on allegations that the facility failed to provide adequate pressure ulcer care and pain management for Resident 1. The complaint was substantiated with findings of immediate jeopardy and actual harm.

The facility failed to provide appropriate pressure ulcer care, including consistent wound assessments, timely dressing changes, and pain management for R1. The wound worsened from Stage 3 to Stage 4 with infection and osteomyelitis, leading to hospitalization and death. Pain medication was not administered before or after dressing changes despite documented pain.

The complaint investigation was triggered by concerns about Resident 1's worsening Stage 4 pressure ulcer, inadequate wound care, untreated pain, and subsequent hospitalization and death due to sepsis related to the wound infection.

The facility failed to provide appropriate pressure ulcer care, including prevention of worsening, consistent wound monitoring, timely physician involvement, and adequate pain management. Resident 1 developed a Stage 4 pressure ulcer with infection, sepsis, and ultimately died. The facility also failed to provide pain relief during dressing changes despite documented pain.

The facility identified multiple deficiencies related to catheter care, diabetes management, skin observation, infection control, employee hygiene, and reporting accuracy. Corrective actions include staff education, policy reviews, and ongoing monitoring to ensure compliance.

The facility was found deficient in multiple areas including resident dignity, comprehensive care planning, professional standards of care, catheter care, nursing staff competency, food safety, payroll-based journal reporting, quality assurance committee attendance, and infection prevention and control practices.

The facility had multiple deficiencies including failure to ensure resident dignity, incomplete care plans, inadequate professional care standards, improper catheter care, insufficient staff competency in skin assessments, unsafe food handling practices, inaccurate staffing data submission, lack of evidence of quality assurance committee attendance, and failure to follow infection prevention protocols.

The facility failed to ensure quarterly reviews of the emergency management plan with residents and staff, failed to serve food at proper temperatures, failed to store food under safe and sanitary conditions, and failed to comply with tuberculosis screening guidelines for residents.

The facility had multiple deficiencies including failure to notify physician of significant resident changes, failure to report and investigate abuse, failure to develop and update comprehensive care plans, inadequate discharge planning, inconsistent bathing and ADL care, failure to prevent falls, inappropriate psychotropic medication use, and lack of an antibiotic stewardship program.

The facility was found deficient in multiple areas including failure to notify physicians of significant resident condition changes, failure to report resident-to-resident abuse, inadequate investigation of falls, incomplete and outdated care plans, inconsistent bathing services, failure to prevent urinary tract infections, improper use of psychotropic medications, and lack of an antibiotic stewardship program.

The complaint investigation revealed failures in public posting of complaint survey results, fall care plan revisions and fall prevention interventions, appropriate use of antipsychotic medication, and safe food storage practices.

The facility failed to ensure complaint survey results from the last three years were available for public review. The facility also failed to revise fall care plans and implement timely interventions to prevent falls for several residents, placing them at risk for injury. Additionally, the facility failed to ensure an appropriate diagnosis for the use of antipsychotic medication for one resident and failed to store food in a safe and sanitary manner, placing residents at risk for foodborne illness.

The visit was triggered by complaint investigations #163711 and #163876. The facility was found noncompliant in multiple areas including public availability of complaint survey results, fall care planning and prevention, psychotropic medication use, and food safety.

The facility failed to ensure complaint survey results from the last three years were available for public review, failed to revise fall care plans and implement fall prevention interventions for multiple residents, failed to provide adequate supervision to prevent falls, failed to ensure appropriate diagnosis for antipsychotic medication use, and failed to store food in a safe and sanitary manner.

The Plan of Correction outlines corrective actions for multiple deficiencies including incomplete liability notices, recliner assessments, significant change assessments, care plan updates, weight loss monitoring, fall investigations, infection control, staff training, and QAPI program improvements.

The facility had multiple deficiencies including failure to provide required Medicare notices, failure to maintain a restraint-free environment, incomplete assessments and care plans, inadequate nutrition management, insufficient nurse aide training, poor infection control, and lack of quality assurance program effectiveness.

The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was reviewed and accepted, resulting in a finding of substantial compliance effective April 2, 2019.

Complaint investigation #138900 involved allegations of abuse, neglect, exploitation, or mistreatment. The facility failed to report an incident timely, with reporting delayed by 24 days. Administrative staff acknowledged breakdowns in the reporting system.

The facility failed to timely report an incident involving a resident's laceration requiring emergency care, failed to update care plans after accidents and falls for three sampled residents, and failed to provide wound care as ordered by the physician for one resident.

The survey found the most serious deficiency to be a widespread 'F' level deficiency that constitutes no actual harm but has the potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 2018-12-05.

The plan addresses multiple deficiencies including resident dignity during meals, safety hazards related to chemical storage and appliance use, nursing staff competency, medication regimen reviews, dietary concerns with pureed diets, and infection control practices including isolation precautions and PPE use.

The visit was complaint-related as indicated by the Health Resurvey and Complaint Investigations #133812 and #133728. Specific complaints included failure to promote resident dignity, unsafe environment hazards, nursing competency issues, medication management concerns, nutrition preparation, and infection control breaches.

The facility failed to promote resident dignity during dining, ensure a safe environment free of hazards, implement nursing competency validation, follow up on pharmacist recommendations for psychotropic medications, prepare pureed food properly, and maintain infection prevention and control practices including proper glove use and cleaning protocols.

The plan addresses deficiencies related to housekeeping and maintenance, accident hazards, and drug records management. Corrective actions include environmental quality improvements, securing hazardous items, and updating medication storage and monitoring procedures.

The facility failed to maintain a sanitary and comfortable environment due to persistent urine odor in a resident's room and hallway, failed to provide an environment free from accident hazards due to unsecured knives and tools, and failed to ensure medications were properly labeled and not expired in the medication room.

The survey found the most serious deficiencies to be 'E' level, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.

This Plan of Correction responds to deficiencies identified during a complaint investigation at Good Sam Cheyenne dated 11/23/2016.

The plan addresses multiple deficiencies related to care plan revisions, resident change of condition protocols, treatment and services for pressure sores, and nurse aide registry verification. The facility outlines corrective actions including staff education, policy adherence, and ongoing monitoring.

Complaint investigation #108073 focused on care planning, treatment, and staff registry verification. The complaint was substantiated with findings of deficient care and documentation leading to resident harm and death.

The facility failed to update a resident's care plan to include physician-ordered pressure reducing boots, failed to thoroughly assess and document a resident's condition after a hospital return leading to resident death, failed to provide necessary treatment to prevent pressure ulcers, and failed to follow up on background check results for several employees.

The facility was found not in substantial compliance and was cited for deficiencies constituting immediate jeopardy to resident health or safety from November 11 through November 23, 2016. Enforcement remedies including denial of payment for new admissions were imposed.

The plan outlines corrective actions for multiple deficiencies including notification of significant changes, activities for cognitively impaired residents, environmental hazards, food nutritive value and handling, and infection control procedures.

The survey found the most serious deficiencies to be 'E' level deficiencies, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan.

The facility was found deficient in multiple areas including failure to notify the physician of changes in resident condition, failure to provide individualized activities, failure to provide thickened liquids as ordered leading to choking risk, failure to maintain food temperature and palatability for pureed meals, unsafe food handling and storage practices, and improper storage of oxygen and respiratory equipment increasing infection risk.

The facility addressed three deficiencies related to nursing assessment, physician notification, and medication administration through refresher trainings and policy updates. The plan includes monthly monitoring of deficiency remedies at QAPI meetings.

The survey found the most serious deficiencies at the facility to be at 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

This action is based on deficiencies found on the current survey and a complaint survey conducted on September 20, 2015.

The revisit found the most serious deficiency to be a 'G' level deficiency, indicating actual harm or above. Due to these deficiencies, a denial of payment for new Medicare and Medicaid admissions was imposed effective September 20, 2015, and termination of the provider agreement was recommended if substantial compliance was not achieved by February 27, 2016.

The report confirms that deficiencies identified under regulations 483.20(d), 483.20(k)(1), and 483.25(h) were corrected by 08/27/2015. No uncorrected deficiencies remain.

Complaint #91506 triggered the investigation. The complaint was substantiated as the facility failed to notify the physician timely, failed to provide adequate care, and failed to administer medications as ordered.

The facility failed to notify the physician of a resident's change in condition related to a urinary tract infection (UTI) for 6 days, failed to provide necessary care and services resulting in hospitalization for sepsis, and failed to administer prescribed antibiotics resulting in significant medication errors.

The report confirms that deficiencies previously reported under regulations 483.20(d), 483.20(k)(1), and 483.25(h) were corrected by 08/27/2015.

The survey found the facility was not in substantial compliance and that conditions constituted immediate jeopardy to resident health or safety from July 12, 2015 through August 27, 2015 related to F309, CFR 483.25 and F323, CFR 483.25(h). Enforcement remedies including denial of payment for new admissions were imposed.

Complaint Investigation #89746 was conducted due to concerns about failure to notify physician of resident condition changes, inadequate care planning, and inadequate supervision leading to resident harm and death.

The facility failed to notify the physician about a resident's prolonged constipation leading to fecal impaction and subsequent death. Additionally, the facility did not develop a comprehensive care plan for bowel management and failed to provide adequate supervision for a cognitively impaired resident who eloped from the facility while seat belted in a wheelchair.

This Plan of Correction responds to deficiencies cited during a complaint investigation at Good Sam Cheyenne.

The plan addresses deficiencies related to elopement risk and bowel management, including staff training, policy updates, and monitoring procedures to ensure compliance and resident safety.

The facility addressed multiple deficiencies related to housekeeping, care planning, medication management, accident hazards, drug regimen, medication errors, and infection control. Corrective actions include staff education, policy revisions, equipment updates, and contracting a new pharmacy consultant.

The survey found a most serious deficiency at level "F", widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.

The facility failed to maintain a sanitary, orderly, and comfortable environment, failed to revise care plans and assess neurological status after falls, failed to prevent accidents and medication errors, failed to obtain weekly blood pressures for residents on anti-hypertensive medications, and failed to maintain an effective infection control program.

The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

All deficiencies previously reported were corrected as of 09/13/2013, with no uncorrected deficiencies noted at the time of this revisit.

The report confirms that the deficiency identified under regulation 26-40-303 was corrected as of 2013-09-13. No other deficiencies are listed as outstanding or corrected.

The facility failed to maintain resident dignity and respect during dining, failed to revise nursing care plans related to nutritional supplements, failed to provide necessary assistance for dependent residents with ADLs, failed to ensure a safe environment due to excessively hot water temperatures, failed to prevent unnecessary drug use for insomnia, failed to properly dispose of garbage, failed to ensure pharmacist reporting of medication irregularities, and failed to maintain adequate infection control in laundry processing.

The plan addresses multiple deficiencies related to dignity and respect for residents, care planning, ADL care, accident hazards, drug regimen management, infection control, and environmental issues such as water temperature and waste disposal. Corrective actions include staff in-service training, monitoring, equipment replacement, and communication with external parties.

The report confirms that all previously reported deficiencies identified on the CMS-2567 were corrected as of the revisit date.

This Plan of Correction responds to deficiencies cited following a complaint investigation conducted on July 3, 2013.

The plan addresses deficiencies involving failure to properly record and track neurological changes, failure to notify physicians of significant condition changes, and inadequate QA committee meetings. Corrective actions include staff in-service training, policy reinforcement, and ongoing monitoring.

The visit was complaint-related, triggered by allegations of inadequate neurological assessments after falls and insufficient supervision to prevent falls. The complaint investigation resulted in an Immediate Jeopardy deficiency and other harm level deficiencies.

The facility failed to provide necessary neurological assessments after falls for 3 sampled residents and failed to ensure adequate supervision and assistive devices to prevent falls. The Quality Assessment and Assurance (QAA) committee also failed to develop and implement appropriate corrective plans following prior deficiencies.

This Plan of Correction is in response to a complaint investigation with deficiencies cited on May 7, 2013. The document references ongoing QA/CQI meetings and staff in-services to address the issues.

The plan addresses deficiencies involving notification of significant changes in resident condition, neurological assessments, and fall prevention interventions. It outlines staff in-services, policy adherence, and ongoing quality assurance activities to ensure compliance.

The investigation was triggered by complaints #KS00064801 and #KS00064672 concerning failure to notify physicians of significant resident condition changes and inadequate care following falls.

The facility failed to immediately notify physicians of significant changes in resident conditions after unwitnessed falls, failed to conduct neurological assessments, and did not implement effective fall prevention strategies. These failures resulted in resident harm including a fatal subdural hematoma and a pelvic fracture. The Quality Assessment and Assurance committee also failed to develop and implement corrective plans.

The investigation was triggered by complaints #KS00062977 and KS00062941 concerning failure to notify physicians of changes in resident condition and inadequate care.

The facility failed to immediately notify the physician of a significant change in a resident's condition, failed to provide care that maintained residents' dignity, failed to provide adequate pain management, and failed to ensure safe transfers for residents requiring assistance.

This Plan of Correction responds to deficiencies cited during a complaint investigation conducted on 02.01.2013.

The plan addresses deficiencies related to notification of changes in resident status, dignity and respect of individuality, provision of care for highest well-being, and free of accident hazards/supervision/devices. The facility outlines corrective actions including staff in-services and audits to ensure compliance.

The revisit report confirms that all previously identified deficiencies under regulations 483.10(b)(11), 483.25(i), 483.35(i), and 483.75(o)(1) were corrected as of June 7, 2012.

The plan addresses deficiencies related to notification of changes in resident condition, maintenance of nutrition status, sanitary food procurement and handling, and quality assurance committee meetings. The facility has scheduled staff in-services and monitoring to ensure compliance with policies.

The facility failed to immediately notify the physician of a resident's severe weight loss and failed to maintain acceptable nutritional status for that resident. Additionally, the facility failed to store, prepare, and serve food under sanitary conditions and did not ensure physician attendance at quality assessment and assurance committee meetings.

The plan addresses deficiencies related to pressure ulcers and skin breakdown, noting that resident #1 was discharged and deceased, and that staff education on the issue was completed with substantial compliance verified.

The plan details corrective actions for multiple deficiencies related to resident care, notification procedures, care plan updates, fall investigations, catheter care, and staff education. The facility commits to monitoring and completing these actions by specified dates.

The plan outlines corrective actions related to resident care plans, incident investigations, abuse/neglect reporting, medication administration, and wound care to address identified deficiencies and prevent recurrence.

The plan outlines corrective actions addressing multiple deficiencies such as updating fall interventions in care plans, implementing oxygen tubing changes, ensuring proper psychotropic medication diagnoses, and improving food labeling and freezer maintenance procedures.