Cheyenne County Village Inc

Inspectors wroteThe facility identified a census of 43 residents with three residents reviewed for pressure ulcers. Based on record review and interview, the facility failed to identify, monitor, and provide appropriate treatments and interventions, to prevent pressure ulcers from worsening and prevent infection for Resident (R) 1. R1 admitted to the facility on [DATE] with a Stage 3 pressure ulcer (full thickness pressure injury extending through the skin into the tissue below) on his coccyx (area at the base of the spine). Nursing staff did not perform consistent wound assessments to include measurements and presence of infection. On 09/08/23, 81 days after admission, R1's wound had worsened and had foul-smelling yellow drainage. A wound culture recorded R1 had Methicillin-Resistant Staphylococcus Aureus (MRSA-a type of bacteria resistant to many antibiotics) and Escherichia coli (E. [...]

Inspectors wroteThe facility identified a census of 43 residents with three residents reviewed for pain. Based on record review and interview, the facility failed to provide Resident (R) 1 with pain relieving measures prior to or after pressure ulcer dressing changes though R1 had documented pain and demonstrated signs of discomfort during dressing change. This deficient practice resulted in untreated pain for R1 and placed him at risk for continued unnecessary pain and altered psychosocial well-being.

Inspectors wroteThe facility had a census of 24 residents. The facility identified one main kitchen. Based on observation, record review, and interview the facility failed to prepare, store, and serve food in accordance with professional standards for food service safety for the 24 residents who resided in the facility and received their food from the facility kitchen, when facility failed to ensure clean and sanitary food prep areas. The facility kitchen staff failed to label and date food in the kitchen refrigerator and freezer. This placed the 24 residents, who resided at the facility and received food from the facility kitchen at risk for receiving foodborne illness.

Inspectors wroteThe facility had a census of 24 residents. Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

Inspectors wroteThe facility had a census of 24 residents. The sample included 12 residents. Based on record review and interview, the facility lacked evidence the required committee members attended the Quality Assessment and Assurance (QAA) committee quarterly meetings. This placed the residents who resided in the facility at risk for decreased quality of care.

Inspectors wroteThe facility had a census of 24 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure Resident (R) 22 was treated with dignity, when staff failed to provide a privacy bag for his indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag). This placed the resident at risk for an undignified experience.

Inspectors wroteThe facility had a census of 24 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan to include Resident (R)9's diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). This deficient practice placed the resident at risk for inappropriate care due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 24 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to provide care which met professional standards for Resident (R) 9's treatment of hypoglycemia (low blood sugar) when staff adminstered liquids orally to R9 while R9 had decreased consciousness. This placed the resident at risk for further complications including choking.

Inspectors wroteThe facility had a census of 24 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to provide appropriate care for Resident (R) 20's suprapubic catheter (urinary bladder catheter inserted through the abdomen into bladder), placing R20 at risk for infection.

Inspectors wroteThe facility had a census of 24 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to ensure staff possessed the skill and knowledge required to conduct a thorough skin assessment in order to identify and treat R22's skin conditions. This placed R22 at risk for ongoing and worsening skin break down.

Inspectors wroteThe facility had a census of 24 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed follow acceptable standards of infection control when staff failed to provide adequate hand hygiene during personal cares for Resident (R)22 and R7. This placed the residents at increased risk for infection.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents. Based on record review and interview the facility failed to maintain an ongoing infection surveillance program which included antibiotic stewardship. This placed the 27 residents who resided in the facility at increased risk for receiving an infection and/or negative effects of antibiotic use.

Inspectors wroteThe facility had a census of 27. The sample included 12 residents. Based on record review and interview the facility failed to notify Resident (R) 28's physician of an unintended indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) removal and a decline of condition within 24 hours of death. The placed the R28 at risk for unmet care and services.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents with two residents reviewed for abuse and four residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to report resident to resident abuse to the appropriate State Agency (SA). This placed the facility's residents at risk of ongoing abuse.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents with two residents reviewed for abuse and four residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to investigate an unwitnessed fall for cognitively impaired Resident (R) 17. This placed the resident at risk for unidentified and/or ongoing abuse or neglect. Findings Included: - The Electronic Medical Record (EMR) documented R17 had diagnoses of dementia with behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion caused by decreased blood flow to the brain), hypertension (high blood pressure), diabetes mellitus type 2 (when the body's ability to produce or respond to the hormone insulin is impaired), and overactive bladder (a problem with bladder function that causes the sudden need to urinate). [...]

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for one sample resident, Resident (R) 3, who had a diagnosis of severe thrombocytopenia (deficiency of platelets in the blood causing bleeding into the tissues, bruising, and slow blood clotting after injury). This placed the resident at risk of complications related to bleeding or bruising.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to update care plan with interventions for Resident (R)15, R7and R23. This deficient practice placed the residents at risk for unmet care needs.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents, with one reviewed for discharge. Based on interview and record review, the facility failed to develop a discharge plan for one sampled resident, Resident (R) 27, who admitted to the facility for skilled therapy. This placed the resident at risk for unidentified discharge goals and impaired discharge planning.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents, with two reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide consistent bathing services for Resident (R) 3 who required staff assistance with bathing. This placed the residents at risk for complications related to poor hygiene. Findings Included: - The Electronic Medical Record (EMR) recorded R3 had diagnoses of dementia without behavioral disturbances (a progressive mental disorder characterized by failing memory and confusion caused by decreased blood flow to the brain), weakness (lacking strength), thryombocytopenia (deficiency of platelets in the blood causing bleeding into the tissues, bruising, and slow blood clotting after injury), and hypertension (high blood pressure). [...]

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents, with two reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide consistent bathing services for Resident (R)17. This placed the resident at risk for complications related to poor hygiene.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents with one reviewed for constipation. Based on observation, record review, and interview, the facility failed to identify and provide interventions for lack of bowel movements for Resident (R) 23 who had a history of constipation (difficulty in emptying the bowels). This placed the resident at risk for impaction (a mass of dry, hard stool that cannot pass out of the colon or rectum).

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents, with four reviewed for falls. Based on observation, record review, and interview, the facility failed to implement meaningful, resident centered interventions to prevent falls for Resident (R) 17, and R23. This placed the residents at increased risk for falls and fall related injury.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents with two reviewed for urinary catheter (tube inserted into bladder to drain urine into a collection bag). Based on observation, record review, and interview the facility failed to provide appropriate treatment and services to prevent urinary tract infections, when staff failed to ensure R22's, who had a history of urinary tract infections (UTIs- infection of any part of the urinary system), urinary catheter bag remained off contaminated surfaces. This placed R22 at increased risk for recurring UTI and related complications.

Inspectors wroteThe facility had a census of 27. The sample included 12 residents. Based on record review and interview the facility failed to ensure staff possessed the skills and knowledge necessary to accurately assess and respond to changes in Resident (R) 28's condition which included physician involvement and notification. The placed the R28 at risk for unmet care and services.

Inspectors wroteThe facility had a census of 27 residents. The sample included twelve residents with two reviewed for behaviors. Based on observation, interview, and record review, the facility failed to provide dementia (progressive mental disorder characterized by failing memory, confusion) care and services to maintain the highest practicable level of wellbeing for Resident (R)15. This placed the resident at risk decreased quality of life.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure Resident (R)7's as needed Ativan (an antianxiety medication) had a stop date and Seroquel (antipsychotic medication used to treat psychosis and other mental emotional conditions) had an approved diagnosis as required, and further failed to ensure R17 had an approved diagnosis for the use of risperidone (antipsychotic). This practice placed R7 and R17 at risk for adverse side effects related to psychotropic (altering mood or mind) medication use.

Inspectors wroteThe facility had a census of 28 residents. Based on observation and interview, the facility failed to store food in a safe and sanitary manner for the 28 residents that resided in the facility and received meals from the kitchen. Findings Included: - On 07/21/21 at 08:40 AM, observation during initial kitchen tour revealed the commercial double door refrigerator contained the following items: five hamburger patties in a plastic bag with no date opened one plastic bag with two hard boiled eggs with no date when the eggs were boiled one half full opened package of approximately 100 pieces Hormel fully cooked bacon with no date opened. On 07/21/21 at 09:00 AM, observation of the upright freezer revealed the following opened, frost covered, and undated items: [...]

Inspectors wroteThe facility had a census of 28 residents. The sample included 12 residents, with six reviewed for falls. Based on observation, record review, and interview, the facility failed to revise three of six sampled residents' fall care plans, Resident (R) 6, R11, and R15.

Inspectors wroteThe facility had a census of 28 residents. The sample included 12 residents, with six reviewed for accidents. Based on observation, record review, and interview, the facility failed to prevent accidents for three of six sampled residents, Resident (R) 6, R11, and R15.

Inspectors wroteThe facility had a census of 28 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, record review, and interview, the facility failed to ensure an appropriate diagnosis for one of the five sampled residents, Resident (R) 24's antipsychotic (medication used to treat any major mental disorder characterized by a gross impairment in reality testing) medication Zyprexa.

Inspectors wroteThe facility had a census of 28 residents. The sample included 12 residents. Based on record review and interview, the facility failed to ensure the last three years complaint survey investigation results were available for public review.