Most Recent Deficiencies for Cheyenne County Village Inc

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Updated as of April 01, 2022

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?
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
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2019-08-15 2019-09-19 N
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Health 2019-08-15 2019-09-19 N
Assess the resident when there is a significant change in condition Health 2019-08-15 2019-09-19 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2019-08-15 2019-09-19 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2019-08-15 2019-09-19 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 2019-08-15 2019-09-19 N
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2019-08-15 2019-09-19 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2019-08-15 2019-09-19 N
Provide enough food/fluids to maintain a resident's health. Health 2019-08-15 2019-09-19 N
Observe each nurse aide's job performance and give regular training. Health 2019-08-15 2019-09-19 N
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. Health 2019-08-15 2019-09-19 N
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Health 2019-08-15 2019-09-19 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2019-08-15 2019-09-19 N
Provide or get specialized rehabilitative services as required for a resident. Health 2019-08-15 2019-09-19 N
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2019-08-15 2019-09-19 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2019-08-15 2019-09-19 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2019-08-15 2019-09-19 N
Provide and implement an infection prevention and control program. Health 2019-08-15 2019-09-19 N
Implement a program that monitors antibiotic use. Health 2019-08-15 2019-09-19 N
Establish an Emergency Preparedness Program (EP). Fire Safety 2019-07-09 2019-08-22 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2019-07-09 2019-08-22 N
Develop a communication plan. Fire Safety 2019-07-09 2019-08-22 N
Establish emergency prep training and testing. Fire Safety 2019-07-09 2019-08-22 N
Have properly located and lighted "Exit" signs. Fire Safety 2019-07-09 2019-08-22 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 2019-07-09 2019-08-22 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2019-07-09 2019-08-22 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2019-07-09 2019-08-22 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2019-07-09 2019-08-22 N
Have simulated fire drills held at unexpected times. Fire Safety 2019-07-09 2019-08-22 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2019-07-09 2019-08-22 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2019-07-09 2019-08-22 N
Ensure proper usage of power strips and extension cords. Fire Safety 2019-07-09 2019-08-22 N
Have proper medical gas storage and administration areas. Fire Safety 2019-07-09 2019-08-22 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2018-11-05 2018-12-05 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2018-11-05 2018-12-05 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 2018-11-05 2018-12-05 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2018-11-05 2018-12-05 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2018-11-05 2018-12-05 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2018-11-05 2018-12-05 N
Provide and implement an infection prevention and control program. Health 2018-11-05 2018-12-05 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2018-06-05 2018-07-05 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2018-06-05 2018-07-05 N
Address subsistence needs for staff and patients. Fire Safety 2018-06-05 2018-07-05 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2018-06-05 2018-07-05 N
Establish policies and procedures for sheltering. Fire Safety 2018-06-05 2018-07-05 N
Establish policies and procedures for medical documentation. Fire Safety 2018-06-05 2018-07-05 N
Establish policies and procedures for volunteers. Fire Safety 2018-06-05 2018-07-05 N
Create arrangements with other facilities to receive patients. Fire Safety 2018-06-05 2018-07-05 N
Establish roles under a Waiver declared by secretary. Fire Safety 2018-06-05 2018-07-05 N
Develop a communication plan. Fire Safety 2018-06-05 2018-07-05 N
List the names and contact information of those in the facility. Fire Safety 2018-06-05 2018-07-05 N
Provide emergency officials' contact information. Fire Safety 2018-06-05 2018-07-05 N
Provide primary/alternate means for communication. Fire Safety 2018-06-05 2018-07-05 N
Establish methods for sharing information. Fire Safety 2018-06-05 2018-07-05 N
Provide a means of sharing information on occupancy/needs. Fire Safety 2018-06-05 2018-07-05 N
Provide family notifications of emergency plan. Fire Safety 2018-06-05 2018-07-05 N
Establish emergency prep training and testing. Fire Safety 2018-06-05 2018-07-05 N
Have properly located and lighted "Exit" signs. Fire Safety 2018-06-05 2018-07-05 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 2018-06-05 2018-07-05 N
Provide properly protected cooking facilities. Fire Safety 2018-06-05 2018-07-05 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2018-06-05 2018-07-05 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2018-06-05 2018-07-05 N
Install corridor and hallway doors that block smoke. Fire Safety 2018-06-05 2018-07-05 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2018-06-05 2018-07-05 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2018-06-05 2018-07-05 N
Provide a written emergency evacuation plan. Fire Safety 2018-06-05 2018-07-05 N
Have simulated fire drills held at unexpected times. Fire Safety 2018-06-05 2018-07-05 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2018-06-05 2018-07-05 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2018-06-05 2018-07-05 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2018-06-05 2018-07-05 N
Ensure proper usage of power strips and extension cords. Fire Safety 2018-06-05 2018-07-05 N
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. Fire Safety 2018-06-05 2018-07-05 N