Life Care Center of Cheyenne

Based on resident representative and staff interview, medical record review, and policy and procedure review, the facility failed to ensure a notification of change of condition was given for 1 of 3 sample residents (#6) reviewed for a change in condition. The findings were:1.Review of the 1/12/26 annual MDS assessment showed resident #6 had a BIMS score of 11 out of 15 (which indicated mild cognitive impairment); showed no signs or symptoms of delirium, behaviors, or hallucinations; was continent of both bladder and bowel, and was independent with personal hygiene, oral hygiene, and toileting hygiene. The resident had diagnoses which included non-Alzheimer's dementia and depression. The findings were:a. Telephone interview with the resident's representative on 3/26/26 at 11:51 AM revealed the resident had a urinary tract infection (UTI) in February. Further, the resident's representative stated the resident had told her s/he was taking medication for an infection. At that time the resident's representative contacted the facility to obtain information related to the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, medical record review, and staff and resident interview, the facility failed to promote and facilitate resident choice and preferences for 1 of 2 sample residents (#12) reviewed. The findings were:1. Review of the 7/21/25 admission MDS assessment showed resident #12 had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included cancer, malnutrition, frequent pain, rheumatoid arthritis and muscle weakness. Further review showed the resident had major surgical procedures prior to admission to the facility which involved placement of nephrostomy tubes and a colostomy. The following concerns were identified: a. Observation on 9/24/25 at 2:31 PM showed RN #1 was changing the resident's dressings following a shower. The resident was lying in his/her bed with his/her upper body exposed and was visibly shivering. The resident verbalized that s/he was cold and CNA #1 offered to turn up the heat. RN #1 responded stating Please don't right now. RN #1 was observed wearing PPE (personal protective equipment), which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and medical record review, the facility failed to ensure a Level II PASRR (preadmission screening and resident review) evaluation was completed prior to admission for 1 of 1 residents (#123) reviewed. The findings were: 1. Review of the 8/20/25 admission MDS assessment showed resident #123 had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included bipolar disorder, anxiety disorder and cerebrovascular accident, transient ischemic attack, or stroke. The following concerns were identified: a. Review of the resident's PASRR Level I, dated 8/14/25, showed evidence of a mental illness which required a PASRR Level II screening prior to admission to the facility. Further review of the resident's medical record showed no evidence a PASRR Level II evaluation had been completed. 2. Interview with the NHA on 9/15/25 at 9:40 AM confirmed a PASRR Level II was not completed prior to admission.

Based on observation, policy and procedure review, medical record review, and resident and staff interview, the facility failed to ensure effective pain management was provided to 1 of 4 residents (#12) reviewed for pain management. The findings were: 1. Review of the 7/21/25 admission MDS assessment showed resident #12 had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included cancer, frequent pain, rheumatoid arthritis and muscle weakness. Further review showed the resident had major surgical procedures prior to admission to the facility which involved placement of nephrostomy tubes and a colostomy. Review of the September 2025 medication administration record showed the resident was last administered 5 milligrams (mg) of oxycodone on 9/24/25 at 7 AM for a pain rating of 7 out of 10 and 500 mg of acetaminophen was administered on 9/23/25 at 9 PM. The following concerns were identified: a. Observation on 9/24/25 at 2:31 PM showed RN #1 was preparing dressing change supplies for resident #12 which was to be completed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and review of policy and procedures and standards of practice, the facility failed to ensure effective infection prevention practices were implemented during one random observation of linen transportation. The census was 119. The findings were: 1. Observation on 9/22/25 at 2:11 PM showed an unidentified staff member was walking down the rehabilitation hall with unbagged soiled towels in her ungloved hands and was transporting them to the soiled linen room. 2. Interview with the infection prevention coordinator on 9/25/25 at 11:56 AM revealed soiled linen should be bagged before removing them from the residents' room and remain bagged while being transported to the laundry room. 3. Review of the Centers for Disease Control and Prevention standards of practice titled Laundry and Bedding, last revised 1/08/24, showed soiled laundry should be bagged prior to transporting to the soiled linen room. 4. Review of the facility policy titled Infection Prevention and Control Program (IPCP) and Plan, last revised 6/02/25, showed personnel must handle,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure medications were safely stored during 1 of 2 observations of medication administration. The census was 113. The findings were: 1. Observation on 9/5/24 at 10:13 AM showed RN #1 removed a medication cup, which was not labeled and had 4 capsules in it, and placed it on the top of the medication cart in a plastic basket on an ice pack. Further observation showed the RN walked away from the medication cart and the medication remained in the basket. 2. Interview with RN #2 on 9/5/24 at 10:17 AM revealed medications should not be left unattended on the top of a medication cart. Observation at that time showed RN #2 removed the medications from the top of medication cart. 3. Interview with RN #1 on 9/5/24 at 10:25 AM revealed the medications he placed on top of the cart were probiotics the needed to be cool. Further interview revealed he was not aware the medications could not be left unattended. 4. Review of the facility policy titled Medication Storage dated March 2022 showed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and staff interview, the facility failed to ensure the comprehensive care plan was revised as needed to reflect the resident's current needs for 1 of 23 sample residents (#5). The findings were: 1. Review of the 5/1/24 admission MDS assessment showed resident #5 had a cognitive assessment which determined the resident to be severely impaired. The resident had diagnoses which included traumatic brain dysfunction, Alzheimer's disease, dementia, and anxiety disorder. Review of the physician orders showed the resident was prescribed 25 mg of Seroquel (antipsychotic) daily at bedtime for agitation on 4/27/24 and 25 mg of Zoloft (antidepressant) daily for depression on 5/16/24. Review of the care plan, last revised on 5/30/24, failed to show the care plan had been revised to include goals and interventions related to the diagnosis of depression. 2. Interview with the DON on 6/6/24 at 10 AM confirmed the care plan had not been updated to reflect the use of the antidepressant medication.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure medication-specific target symptoms were identified and monitored for 2 of 5 sample residents (#5, #29) reviewed for unnecessary medication use. The findings were: 1. Review of the 5/21/24 MDS assessment showed resident #29 had a BIMS score of 10 out of 15, which indicated moderate cognitive impairment, and diagnoses which included Parkinson's disease, dementia, anxiety, and depression. Review of the most current physician orders showed the resident received 25 (mg) of Seroquel (antipsychotic) by mouth in the evening related to psychotic disorder with hallucinations, 25 mg of Zoloft (antidepressant) by mouth one time a day related to depression, and 34 mg of Nuplazid (atypical antipsychotic) by mouth one time a day for Parkinson's related hallucinations. The following concerns was identified: a. Review of the June 2024 Behavior Monitoring & Interventions task showed the resident could be verbally and physically aggressive, exhibited inappropriate sexual behavior, had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure 1 of 2 medical record storage areas (Therapy West) were safeguarded from unauthorized use. The findings were: 1. Observation on 2/27/23 at 1:58 PM of the Therapy [NAME] hall showed resident medical records were kept in a cabinet. Both doors of the cabinet were observed to be off the hinges. At that time 12 resident medical records were seen. The storage area was across from the nurses' desk, and a restroom. Further observation showed throughout the four days of the recertification survey the medical records were easily accessible and were available for unauthorized use. 2. Interview with LPN #2 on 2/28/23 at 11:13 AM confirmed the records were available for anyone to access. Further, the LPN stated she was unsure of the how long the doors had been broken. 3. Interview with the DON on 2/28/23 at 4:59 PM revealed it was the facility's expectation for the residents' medical records to be kept in a secure cabinet with the doors closed. Further, the DON stated she was aware the cabinet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interview, and review of facility policy and procedure, the facility failed to ensure 2 of 26 sample residents (#19, #28) had resident-specific care plans that reflected individual needs in all required areas. The findings were: 1. Review of the medical record for resident #19 showed s/he was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, insomnia, PTSD (post-traumatic stress disorder), dementia with psychotic disturbance, neuroleptic induced Parkinsonism, muscle weakness and lack of coordination. Review of the 2/3/23 quarterly MDS assessment showed the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of the physician's orders, printed 3/1/23, showed orders for Abilify (antipsychotic) 10 milligrams and Cymbalta (antidepressant) 90 milligrams, by mouth, daily for major depression. Interview with the resident on 3/2/23 at 11:30 AM revealed s/he was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and staff interview, the facility failed to follow physician's orders for 1 of 26 sample residents (#73) reviewed. The findings were: 1. Review of the 1/13/23 quarterly MDS assessment showed resident #73 had a BIMS score of 99 indicating the resident was unable to complete the interview (severely impaired - never/rarely made decisions) and diagnoses which included diabetes mellitus and long term use of insulin. Further review showed the resident received insulin injections 7 days of the 7-day look-back period. Review of the physician's orders, printed 2/28/23, showed the facility was to check blood sugars before meals and at bedtime. The orders specified to call the physician if the blood glucose was less than 70 mg/dl or greater than 460 mg/dl. The following concerns were identified: a. Review of January 2023 MAR showed the resident had blood glucose levels less than 70 mg/dl on 1/12/23 and 1/15/23. Review of February 2023 MAR showed a greater than 460 mg/dl level on 2/2/23 and 2/3/23 and less than 70 mg/dl level on 2/10/23 at two different times.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, policy and procedure review, and professional standard review the facility failed to ensure medications were labeled in accordance with professional standards in 1 of 4 medication storage units (Therapy South medication cart). The finding were: 1. Observation on 3/2/23 at 9:45 AM of the Therapy South medication cart showed 2 insulin glargine 100 unit/milliliter flex pens with no open date, and 1 insulin lispro 100 unit/milliliter kwikpen with no open date. Interview at that time with RN #1 confirmed the medications were for resident use. Further, the RN stated she was unaware when the medications would expire. 2. Interview with the DON on 3/2/23 at 10:31 AM revealed it was the facility's expectation for the insulin containers to be dated with an open date when they come out of the refrigerator for use. 3. Review of policy Guidance for Using Insulin Products dated 2021 Omnicare, showed 1. Storage of Product .b.Storage of unopened insulin products outside of the refrigerator is permissible, but results in an earlier expiration date.After opening…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.