Above average — CMS composite of the measures below.
The next survey window likely opens around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cheyenne Manor during CMS and state inspections, most recent first.
The facility failed to complete annual performance reviews for five CNAs and did not provide regular in-service education based on those reviews. Record review showed no documentation of annual evaluations for the CNAs, and the NHA stated that performance evaluations were not conducted and CNA raises were based on cost of living decisions by the board.
Failure to document and resolve grievances: A cognitively intact resident with anxiety, OA, and dementia reported repeated unresolved concerns about a toilet seat riser, window blinds/curtains, and an activities assistant. The facility had no grievance forms, no written resolution provided to the resident, and no records showing the complaints were addressed.
Failure to Protect a Resident from Caregiver Neglect: A CNA refused to assist a resident with a mechanical-lift transfer after the resident’s spouse requested help, ignored repeated requests, and used profanity toward the spouse when he complained. The resident had TBI, vascular dementia, and stroke, with moderate cognitive impairment and extensive ADL needs. Staff later stated the refusal to provide care constituted neglect, but the incident was treated as a customer service issue rather than an abuse concern.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for five of five certified nurse aides, including CNA #1, CNA #3, CNA #4, CNA #5, and CNA #6. Record review showed that annual performance reviews were requested for these CNAs, but the facility was unable to provide documentation showing that any of them had received an annual performance evaluation. The facility policy stated that all employees are to receive an annual performance review and that evaluations are performed by immediate supervisors. During interview, the nursing home administrator stated that the facility did not conduct annual performance reviews. She said CNA raises were based on cost of living and decided by the board of directors. She also stated that performance evaluations were not conducted and that regular in-service education based on the outcome of those reviews was not provided.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to maintain a system for documenting grievances and showing prompt action for one resident who reported multiple unresolved concerns. The resident, who was over age 75 and had diagnoses including anxiety, osteoarthritis of the right shoulder, and unspecified dementia, was assessed as cognitively intact with a BIMS score of 15 and required moderate staff assistance with dressing, transfers, and bathing. During interview, the resident stated she had repeatedly requested a toilet seat riser for several months, had also complained about window blinds she could not close because she could not raise her arms, and had asked for curtains so she could control the light in her room. She also reported a grievance about an activities assistant who would set up an activity and then leave it. No toilet seat riser or curtains were observed in the resident’s room. Record review did not show documentation that the resident’s grievances had been addressed, and the facility was unable to provide any grievance records for the resident. The social services director stated the facility did not use formal grievance forms and instead typed grievance details into a word document, but there was no written documentation provided back to the resident or complainant and no signed acknowledgment of resolution. The social services director said she had no written grievances for the resident and was unaware of grievances related to the window or activities. The nursing home administrator acknowledged the facility did not have a formal grievance process with grievance forms or written documentation of resolution and stated the facility needed to improve its process to ensure grievances were documented, responded to timely, and resolved satisfactorily.
Failure to Protect a Resident from Caregiver Neglect
Penalty
Summary
The facility failed to ensure Resident #12 was free from abuse when a CNA refused to provide care and used profanity toward the resident’s spouse after being asked to transfer the resident. Resident #12 was admitted with traumatic brain injury, vascular dementia, and stroke, had moderate cognitive impairment with a BIMS score of 9, required moderate to extensive assistance with ADLs, and needed a mechanical lift for transfers. The resident also had right-sided impairments and a contracture to the right hand related to the stroke. According to the spouse, CNA #1 ignored his request for help transferring Resident #12 and continued to refuse even after RN #3 asked her to assist. The spouse reported that CNA #1 used profanity toward him when he complained about the lack of care. RN #3 stated she had to find another CNA to complete the transfer because CNA #1 was unwilling to assist. CNA #1 acknowledged she ignored the spouse and said she did not want to interact with him because of prior accusations, and she stated she had the right to ignore him. The facility’s staff identified that refusal to provide care would constitute neglect, and the SSD stated that using profanity at a family member and refusing to provide care was not a customer service issue but potential neglect of a resident’s needs. The DON and NHA stated the incident was viewed as a customer service issue rather than an abuse concern, and CNA #1 was not suspended, investigated, or removed from the resident’s hall. The NHA stated the facility did not interview staff or other residents to determine whether the incident was part of a pattern or whether there were other potential victims, and acknowledged the refusal to provide care should have been treated as potential neglect and investigated.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cheyenne Wells
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grace Manor Care Center | 33.7 mi | ★★★★★ | 7 | 0 |
| Greeley County Hospital Ltcu | 38.5 mi | ★★★★★ | 19 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.