A list of the most recent deficiencies for Cheyenne County Village Inc. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-11-08 | 2023-11-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-08 | 2023-11-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-11-08 | 2023-11-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-08 | 2023-11-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-08 | 2023-11-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-08 | 2023-11-18 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-11-08 | 2023-11-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-08 | 2023-11-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-08 | 2023-11-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-08 | 2023-11-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-08 | 2023-11-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-08 | 2023-11-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-08 | 2023-11-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-08 | 2023-11-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-08 | 2023-11-18 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-11-08 | 2023-11-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-28 | 2023-10-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-28 | 2023-10-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-28 | 2023-10-25 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-09-28 | 2023-10-25 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-09-28 | 2023-10-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-28 | 2023-10-25 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-09-28 | 2023-10-25 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-09-28 | 2023-10-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-28 | 2023-10-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-11-15 | 2022-12-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-15 | 2022-12-19 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-11-15 | 2022-12-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-15 | 2022-12-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-15 | 2022-12-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-15 | 2022-12-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-15 | 2022-12-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-15 | 2022-12-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-15 | 2022-12-19 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-11-15 | 2022-12-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-15 | 2022-12-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-15 | 2022-12-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-15 | 2022-12-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-13 | 2022-11-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-13 | 2022-11-25 | N |
| Respond appropriately to all alleged violations. | Health | 2022-10-13 | 2022-11-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-13 | 2022-11-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-10-13 | 2022-11-25 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-10-13 | 2022-11-25 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-10-13 | 2022-11-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-13 | 2022-11-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-13 | 2022-11-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-13 | 2022-11-25 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-10-13 | 2022-11-25 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-10-13 | 2022-11-25 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-10-13 | 2022-11-25 | N |
| 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. | Health | 2022-10-13 | 2022-11-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-10-13 | 2022-11-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-08-17 | 2021-09-23 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-08-17 | 2021-09-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-17 | 2021-09-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-17 | 2021-09-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-17 | 2021-09-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-17 | 2021-09-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-17 | 2021-09-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-17 | 2021-09-23 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-28 | 2021-08-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-28 | 2021-08-25 | Y |
| 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. | Health | 2021-07-28 | 2021-08-13 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-07-28 | 2021-08-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-28 | 2021-08-03 | N |
