Cheyenne Medical Lodge

Inspectors wroteBased on interview and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing for one (Resident #1) of six residents reviewed for wound care treatment and services. The facility failed to identify and treat Resident #1's Stage III pressure ulcer that he admitted with at the hospital on [DATE]. This failure could cause residents who are at risk of pressure ulcer injuries or residents with pressure ulcer injures to develop, re-develop, and/or worsen.

Inspectors wroteBased on interviews and record review, the facility failed to ensure assessments accurately reflected the resident's status for one (Residents #1) of sixteen residents reviewed for Accuracy of Assessments. The facility failed to ensure Resident #1's Quarterly MDS assessment dated [DATE] accurately reflected that the resident exhibited rejection of care behaviors related to his ADLs as documented on his Comprehensive Care Plan, progress notes, and shower sheets. These failures could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regression in their overall health. Review of Resident #1's Face Sheet dated 07/10/26 revealed he was a [AGE] year-old male admitted to the facility on [DATE] for rehabilitation. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy during medical treatment and personal care and confidentiality of personal and medical records for seven of twenty residents (Residents #14, #36, #51, #101, #102, #126, and #150) reviewed for privacy and confidentiality. 1. The facility failed to ensure CNA F closed the door and pulled the privacy curtain while doing Resident #126's incontinent care on [DATE]. 2. The facility failed to ensure LVN C secured Residents #14, #36, #51, #101, #102, and #150's medical information before leaving his cart on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for four of eighteen residents (Residents #14, #23, #95, and #131) reviewed for medication storage. 1. The facility failed to ensure that Resident #14's zinc oxide was not on top of the resident's side table on 06/14/2026. 2. The facility failed to ensure that Resident #23's zinc oxide was not on top of the resident's side table on 06/14/2026. 3. The facility failed to ensure that Resident #131's zinc oxide was not on top of the resident's side table on 06/14/2026. 4. [...]

Inspectors wroteBased observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of eighteen residents (Resident #44, #126, and #137) reviewed for infection control. 1. The facility failed to ensure CNA F performed hand hygiene, changed her gloves, and wore a gown during Resident #126's incontinent care on 06/14/2026. 2. The facility failed to ensure CNA F and CNA G wore gowns when Resident #126, who was on enhanced barrier precautions due to pressure ulcer, was repositioned on 06/14/2026. 3. The facility failed to ensure MA D sanitized the blood pressure cuff when used between Resident #44 and Resident #137 on 06/14/2026. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one of eighteen residents (Resident #24) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #24's room was in a position that was accessible to the resident on 06/14/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure assessments accurately reflected the resident's status for one of eight residents (Residents #13) reviewed for accuracy of assessments. The facility failed to ensure Resident #13's Comprehensive MDS Assessment, dated 05/01/2026, accurately reflected that the resident was receiving insulin. This failure could place the resident at risk for not receiving care and services to meet their needs, diminished function of health, and regression in their overall health.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that the residents' environment remained free of hazards as was possible for 2 (Resident # 96 and Resident #95) of 10 residents reviewed for accident and hazards. 1. The facility failed to ensure a bottle of rubbing alcohol was not left on Resident #96's nightstand next to her bed on 06/14/2026. 2. The facility failed to ensure Resident # 95 did not have a can of aerosol hairspray on the overbed table next to her bed on 06/14/2026.3. The facility failed to ensure medications and biologicals were stored in a secure manner by leaving Micro-Kill wipes unattended on a medication cart without staff supervision. These failures could place residents at risk of injuries and exposure to toxic chemicals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for two of ten residents (Resident #44 and Resident #113) reviewed for medication administration. 1. The facility failed to ensure MA D administered Resident #44's medication on time on 06/14/2026. 2. The facility failed to dispose of Resident #113's expired insulin on 06/15/2026. These failures could place residents at risk of not receiving the full therapeutic benefits of the medications and not receiving medications as ordered resulting to adverse effects.

Inspectors wroteBased on observations, record reviews, interviews, the facility failed to ensure that the medication error rate was not five percent or greater. Eleven medication administration errors were identified out of 25 opportunities, yielding a 44.4% error rate for one of five residents (Resident #44) reviewed for medication errors. The facility failed to ensure MA D did not give Resident #44's eight o'clock and nine o'clock medications at 11:30 a.m. on 06/14/2026. This failure could place the residents at risk for treatment failure, disease progression, reduced effectiveness, and adverse reactions.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Residents #2) of five residents reviewed for respiratory care. The facility failed to ensure Resident #2 's breathing mask was stored properly when not in use on 02/17/2026. This failure could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for three (Resident #1, Resident #11, and Resident #42) of eight residents reviewed for Care Plans. 1. The facility failed to ensure Resident #1 was care planned for hospice on 05/04/2025. 2. The facility failed to ensure Resident #11's was care planned for Parkinson's Disease (a movement disorder). 3. The facility failed to ensure Resident #42's was care planned for Parkinson's Disease. These failures could place the residents at risk of not receiving the necessary care and services needed.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 3 of 8 residents (Residents #49, #55, and #61) reviewed for accident prevention. 1. The facility failed to ensure Resident #49, #55, and #61 had physician orders for the for the scoop mattress on their bed. 2. The facility failed to ensure CNA E used a gait belt when transferring Resident #55 from bed to wheelchair on 05/05/2025. These failures could prevent the residents from having an environment that was free and clear of accidents and hazards.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distributed, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. 1. The facility failed to ensure the ice machine and ice scoop holder in the facility kitchen was thoroughly cleaned. 2. The facility failed to ensure kitchen cooking equipment was cleaned. 3. The facility failed to place a cover on top of the tea dispenser to avoid air borne contaminants. 4. The facility failed to ensure prepared food in the refrigerator was labeled and dated when stored. 5. The facility failed to ensure expired food in the refrigerator was discarded. 6. The facility failed to ensure kitchen and dining room equipment was cleaned and sanitized. 7. [...]

Inspectors wroteBased observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Resident #39, Resident #50 and Resident #219) of fifteen residents reviewed for Infection Control. 1. The facility failed to ensure the Wound Care Nurse performed hand hygiene when changing gloves during wound care for Resident #39 on 05/05/2025. 2. The facility failed to ensure CNA K did not take a bedside table from Resident #50's room into the hall with contaminated linens on the bedside table on 05/05/2025. 3. The facility failed to ensure CNA B performed hand hygiene, changed gloves, and wore a gown while performing Resident #219's incontinent care on 05/05/2025. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had the right to be treated with respect and dignity for 1 of 4 residents (Resident #67) reviewed for dignity. The facility failed to ensure staff properly fed Resident #1 breakfast, while he was in bed. This deficient practice could place the resident at risk of not feeling as if they were being treated with dignity and respect.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #42 and Resident #93 ) of eighteen residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light system in Resident #42 and #93's rooms were in a position that was accessible to the resident on 05/04/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for one (Resident #1) of five residents reviewed for Pharmaceutical Services. The facility failed to ensure RN F disposed of Resident #1's Lorazepam (medication for anxiety) properly on 05/04/2025. This failure could place residents at risk of not receiving medications as ordered by the physician.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medication for one (Resident #5) of fifteen residents stored in locked compartments and only authorized personnel had access. The facility failed to ensure Resident 5's zinc oxide (cream used to treat skin irritations, diaper rash, and other skin conditions) was not left on top of the resident's left side table on 05/04/2024. This failure could place the residents at risk of not receiving medications, accidental overdose, or misuse of medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for one (Residents #4,) of three residents reviewed for pharmacy services. 1. The facility failed to administer medications as ordered, Lidocaine HCL at 5% external patch to Resident #4 on 03/18/24, 03/19/24, 03/21/24, 03/24/24,and 03/26/24. These failures placed residents at risk for not receiving the therapeutic effect of their medications as ordered by the physician.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, including acute charting guidelines and post fall procedures necessary to care for resident's needs as identified through resident assessments and nursing documentation, for 1 (Resident #1) of 4 residents reviewed for quality of care. 1. LVN A failed to communicate, use the acute charting guidelines, and post fall procedures, to the oncoming charge nurse at the change of shift, leaving RN B unaware Resident #1's required follow-up assessment, due to a previous fall. These failures placed residents with falls at risk for complications to include discomfort/injury and for residents not to receive needed nursing assessments.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all written grievance decisions included the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for 1 of (Resident #1) of 3 residents reviewed for grievances. 1. The facility failed to file a grievance for Resident #1 when the family of the resident made complaints. The facility's failure could place the residents at risk for concerns not being reported and addressed.