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 |
