Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cheyenne Medical Lodge during CMS and state inspections, most recent first.
A CNA provided incontinent care to a resident without closing the door or pulling the privacy curtain, despite the resident being cognitively intact and incontinent. In a separate incident, an LVN left a cart in the hallway with an untitled shift report exposed, revealing confidential medical information for multiple residents, including code status, hospice status, medication orders, and respiratory equipment use. Interviews confirmed the information should have been secured and privacy maintained during care.
Improper Storage of Medications in Resident Rooms: Surveyors found medicated creams left in plain view on side tables and bedside furniture in multiple residents’ rooms. Residents with dementia and cognitive impairment had zinc oxide cream accessible in their rooms, and another resident had Estradiol Vaginal Cream and pain relief cream at bedside despite an order for nurse administration and no self-administration assessment. Staff and the DON acknowledged these items should not have been left accessible to residents.
A facility failed to maintain infection control during resident care and equipment use. Staff did not perform hand hygiene, change gloves appropriately, or wear gowns during care for a resident on EBP with a pressure ulcer, and a blood pressure cuff was used between two residents without being sanitized. The DON and Administrator stated these practices were expected to prevent cross contamination.
A resident with Alzheimer’s disease and severe cognitive impairment was observed in bed with his call light on the floor and out of reach. The resident could not indicate how he would get help, and a CNA later placed the call light within reach. An LVN, ADON, DON, and the Administrator all stated that staff are responsible for ensuring call lights remain within residents’ reach before leaving the room, consistent with the facility policy.
A resident with diabetes mellitus had a Comprehensive MDS that did not indicate he was receiving insulin or other hypoglycemic medication, even though his record included diabetes treatment orders and his care plan addressed diabetes medication administration. During review, the MDS nurse identified the omission as an oversight and corrected the coding after confirming the resident should have been coded for hypoglycemic medication.
Hazardous items were left accessible in resident areas when a bottle of rubbing alcohol was found on one resident’s nightstand, a can of aerosol hairspray was found on another resident’s overbed table, and Micro-Kill wipes were observed unattended on a med cart without staff supervision. The residents had cognitive impairment noted on MDS, and staff stated they were unaware the items were present or that they should not have been there.
A resident with dementia and multiple scheduled morning meds had her medications administered late, with the MA acknowledging the delay while passing meds in hall 100 and the eMAR marked red. A second resident with DM and severe cognitive impairment had expired Humalog insulin left in the med room refrigerator after being opened beyond the 28-day shelf life, and RN, ADON, and DON all stated it should have been disposed of rather than left with active insulin.
Medication error rate exceeded the facility threshold when an MA administered 11 medications to a resident with dementia and multiple chronic conditions well after the scheduled 8:00 a.m. and 9:00 a.m. times. The resident’s eMAR was red, and the MA acknowledged the medications were late. The DON and ADON stated medications were expected within the two-hour window and that giving them outside that timeframe was a medication error.
A resident with COPD and acute and chronic respiratory failure with hypoxia had physician-ordered nebulizer treatments and a care plan intervention to provide these treatments. During observation, the resident was found asleep in bed with a nebulizer on the nightstand and the attached breathing mask left unbagged. Multiple staff, including a CNA, RN, ADON, Administrator, and DON, stated that respiratory masks and oxygen tubing were expected to be stored in bags when not in use and that nurses were responsible for bagging and dating nebulizer masks after treatments, yet the mask for this resident was not bagged. The facility lacked a specific written policy on storage of respiratory items when not in use.
The facility did not create or implement care plans for a resident on hospice care and two residents with Parkinson's disease, despite documented diagnoses and physician orders. Staff confirmed these omissions, and the lack of care plans meant that necessary interventions and coordination for these conditions were not documented or communicated among care providers.
Three residents with a history of falls and severe cognitive impairment were found to have scoop mattresses on their beds without physician orders or care plan documentation, and a CNA transferred a resident without using a gait belt as required by facility policy. Staff interviews confirmed a lack of awareness and adherence to established protocols for specialty equipment and safe transfer procedures.
Surveyors identified several deficiencies in food storage and sanitation, including unclean ice machines and scoop holders, uncovered tea dispensers, improperly labeled or expired food items in refrigerators, and unsealed frozen foods. The Dietary Manager and Administrator acknowledged these issues, which were not in line with facility policy and could result in cross-contamination.
Multiple lapses in infection control were observed, including a nurse failing to perform hand hygiene between glove changes during wound care for a resident with a wound infection, a CNA transporting a bedside table with contaminated linens into the hallway after incontinence care, and another CNA not performing hand hygiene, not changing gloves appropriately, and not wearing a gown while providing care to a resident on enhanced barrier precautions.
A resident with severe cognitive impairment and total dependence for ADLs was fed breakfast by a CNA who stood over the resident in bed, contrary to facility policy requiring staff to be seated at eye level for dignified care. Staff interviews and policy review confirmed this practice did not honor the resident's right to dignity.
Two residents with cognitive and physical impairments, both at risk for falls, were found without accessible call lights in their rooms. In one case, a resident's call light was wedged between the mattress and bed frame, while in another, the call light was on the floor out of reach. Staff interviews confirmed that call lights should always be within reach, and facility policy requires accessibility for all residents, but this was not consistently ensured.
A nurse failed to immediately dispose of a dropped Lorazepam tablet prescribed for a resident with severe cognitive impairment and hospice care needs. The tablet was left unattended on the floor during medication administration and other tasks before being properly disposed of with a witness, contrary to facility policy and expectations for handling controlled substances.
A resident with moderate cognitive impairment and multiple diagnoses had zinc oxide cream left unsecured on a bedside table after incontinence care, contrary to facility policy requiring all drugs and biologicals to be stored in locked compartments. Staff acknowledged the error and confirmed that the cream should not have been accessible to the resident.
A resident did not receive her prescribed Lidocaine HCL patches on multiple occasions due to ordering and communication issues among staff, leading to inconsistent medication administration.
Privacy and Confidentiality Failures During Resident Care and Record Handling
Penalty
Summary
The facility failed to maintain resident privacy during personal care when CNA F provided incontinent care to Resident #126 without closing the room door or pulling the privacy curtain. Resident #126 was a cognitively intact male with hemiplegia, hemiparesis, and incontinence of bladder and bowel, and his care plan required assistance with ADLs, including toilet use and personal hygiene. During the observation, CNA F entered the room, put on gloves, and proceeded with incontinent care while the door remained open and the privacy curtain was not drawn. The facility also failed to keep confidential medical information secure when LVN C left his cart unattended in the hallway with an untitled paper containing resident information exposed. The paper included names and medical details for Residents #14, #36, #51, #101, #102, and #150, including code status, hospice status, appointment instructions, NPO status, medication holds, BiPAP use, pain management, morphine and lorazepam use, a midline in the left upper arm, and CPAP use. LVN C stated he realized he had not flipped over the shift report and acknowledged that the information should have been secured to prevent HIPAA violations. Interviews with the ADON, DON, and Administrator confirmed that doors should be closed and privacy curtains pulled during care, and that the shift report contained confidential information that should not have been left exposed. The facility policy stated that residents' personal and clinical records are protected to assure confidentiality and that personal privacy will be provided for personal care. The report documented that these privacy and confidentiality failures occurred during direct care and while resident medical information was left visible in the hallway.
Improper Storage of Medications in Resident Rooms
Penalty
Summary
The facility failed to keep drugs and biologicals stored in locked compartments and accessible only to authorized personnel when surveyors found medicated creams left inside residents’ rooms and on bedside furniture. Resident #14, a male with dementia, severe cognitive impairment, and bowel and bladder incontinence, had a sachet of zinc oxide cream on top of his side table during an observation. His clinical assessment list showed no assessment for self-administration of medications or competency to manage medications, and he told staff used the cream every time his brief was changed. Resident #23, a female with dementia and severe cognitive impairment, was also observed with a tube of zinc oxide cream on her side table in plain view. Her record likewise showed no assessment for self-administration of medications or competency to manage medications. She stated staff used the cream every time she was changed and said she did not know who left it on her side table. Resident #131, a female with dementia, reflux uropathy, severe cognitive impairment, and incontinence, had a tube of zinc oxide cream on top of her side table during observation. She said she did not know what the cream was for, but she always saw it on her side table. Resident #95, a female with acute kidney failure, depression, and hypertension, had a tube of Estradiol Vaginal Cream on the over-bed table and a container of pain relief cream on the nightstand. Her physician order reflected the vaginal cream was to be administered by a nurse, and there was no order for the pain cream. Her clinical assessment notes showed no assessment for self-administration of medications or competency to manage medications. Staff interviews confirmed the creams should not have been left at bedside, and the DON stated no medication should be at the resident’s bedside. The facility policy stated all drugs and biologicals are stored in locked compartments.
Infection Control Lapses During Resident Care and Equipment Use
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for three residents reviewed for infection control. Resident #126 was cognitively intact, incontinent, and had a stage 4 pressure ulcer to the left lateral malleolus. During incontinent care, CNA F entered the room and put on gloves without washing his hands first and did not wear a gown. He used the same gloves while cleaning the resident’s bottom, applying cream, handling the soiled brief, and cleaning the resident’s perineal area. He changed gloves once, but did not sanitize his hands before putting on a new pair, and he did not change gloves after touching the soiled brief. He also left the room without washing his hands. The resident had a sign outside the room indicating enhanced barrier precautions and that a gown was required when changing the brief, along with hand cleaning before entering and leaving the room. Resident #126 was later repositioned by CNA F and CNA G, and neither staff member wore a gown. CNA F put on gloves without washing his hands first, CNA G washed her hands in the bathroom and then put on gloves, and both proceeded with repositioning while leaning on the resident’s bed. Both CNAs stated they were not aware the resident was on enhanced barrier precautions and initially thought the sign was for the roommate. CNA F acknowledged he should have washed his hands before care, sanitized his hands when changing gloves, and changed gloves after pulling the soiled brief. CNA G stated a gown should have been worn because repositioning was a high-contact activity. The facility also failed to ensure proper equipment sanitation between residents. MA D used a blood pressure cuff on Resident #137, placed it on the medication cart, prepared and administered medications, and did not sanitize the cuff before using it on Resident #44. She then used the same cuff on Resident #44, again placing it on the medication cart afterward without sanitizing it. MA D stated the facility protocol was to sanitize the blood pressure cuff between uses to prevent cross contamination. The DON and Administrator both stated that hand hygiene, glove changes, gown use for enhanced barrier precautions, and sanitizing the blood pressure cuff were expected infection control practices, and that failure to follow them could contribute to spread of infection.
Call Light Left Out of Reach
Penalty
Summary
The facility failed to ensure reasonable accommodation of a resident’s needs and preferences when Resident #24’s call light was not within reach in the room. Resident #24 was an [AGE]-year-old male with Alzheimer’s disease, severe cognitive impairment, and a BIMS score of 03. His MDS showed he was dependent on staff for transfer, toileting, hygiene, showering, and dressing, and his care plan identified a history of falling with an intervention to keep the call light within reach. During an observation, Resident #24 was in bed awake, and his call light was observed on the floor. When asked what he used when he needed assistance, he shrugged his shoulders. A CNA then found the call light on the floor and placed it within the resident’s reach, stating it may have fallen when he was repositioned and that staff should have ensured it was reachable before leaving the room. An LVN, the ADON, the DON, and the Administrator all stated that call lights should always be within residents’ reach and that staff were responsible for making sure they were in place before leaving the room. The facility policy also stated that the call light must always be within the resident’s reach before leaving the room.
MDS Assessment Did Not Reflect Diabetes Medication
Penalty
Summary
The facility failed to ensure that Resident #13’s Comprehensive MDS Assessment accurately reflected the resident’s status for diabetes treatment. Resident #13 was a cognitively intact male with a BIMS score of 15, diagnosed with diabetes mellitus, and his care plan included an intervention to administer diabetes medication as ordered. However, the Comprehensive MDS Assessment dated 05/01/2026 did not indicate that the resident was receiving insulin or hypoglycemic medication, even though the record included a physician order for Trulicity subcutaneous injection for type 2 diabetes mellitus without complications. During observation and interview on 06/16/2026, the MDS Nurse reviewed the assessment and stated that if a resident was receiving insulin, the resident should be coded as receiving hypoglycemic medications. She found that Resident #13 had not been coded that way and corrected the MDS, stating it was an oversight. The DON, ADON, and Administrator were also interviewed and acknowledged the importance of the MDS reflecting resident needs, with the DON stating the MDS paints the picture of resident needs so appropriate care can be implemented.
Hazardous Items Left Accessible in Resident Areas
Penalty
Summary
The facility failed to keep the residents’ environment free of hazards for 2 of 10 residents reviewed for accident and hazards. On 06/14/2026, a container of rubbing alcohol was observed sitting on the nightstand next to Resident #96’s bed. Resident #96 was a [AGE]-year-old female with diagnoses including osteomyelitis of the thoracic vertebrae, unspecified dementia, and a mood disorder. Her MDS assessment reflected a BIMS score of 12, indicating she was moderately cognitively intact. During the observation, she stated she did not know why the alcohol was there or how long it had been there, and the container had a label stating, “Keep out of reach of children.” The facility also failed to keep another resident’s room free of hazards when a can of aerosol hairspray was observed on the overbed table next to Resident #95’s bed on 06/14/2026. Resident #95 was a [AGE]-year-old female with diagnoses including acute kidney failure, depression, and hypertension, and her MDS assessment reflected a BIMS score of 11, indicating she was moderately cognitively intact. She stated her daughter had brought the hairspray and that she was not aware she was not supposed to have it in her room. In addition, a container of Micro-Kill wipes was observed unattended on a medication cart in front of a resident room with no nursing staff present or monitoring the cart at the time.
Late Medication Administration and Expired Insulin Left in Refrigerator
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident for two residents reviewed for medication administration. One resident had dementia, pleural effusion, drug-induced constipation, GERD, rheumatoid arthritis, hypertension, and anxiety, with severe cognitive impairment and a BIMS score of 06. Her care plan directed that medications be administered at the same time of day. Her physician orders included multiple morning medications, including famotidine, furosemide, lidocaine patch, losartan, metoprolol succinate, Miralax, paroxetine, hydroxychloroquine, senna, and ipratropium nasal spray, with scheduled administration times of 8:00 a.m. or 9:00 a.m. During observation on 06/14/2026 at 11:37 a.m., MA D was seen passing medications in hall 100 and entered the resident’s room to take her blood pressure before preparing the resident’s medications. When asked, MA D stated she was preparing the resident’s morning medications and said she was late for her medications. The resident’s eMAR was observed to be red. During interview, MA D stated that late medication administration might affect residents’ overall health and said the correct procedure was to administer medications one hour before and one hour after the scheduled time. LVN C stated he was not aware MA D was late with medications and said late administration might affect residents’ health because their condition might not improve. The DON stated she was not aware MA D was late and said she would talk to MA D and assess the resident. A second resident had diabetes mellitus and severe cognitive impairment with a BIMS score of 04 and was receiving insulin. Her care plan directed that diabetes medication be administered as ordered. Her physician order included Humalog KwikPen insulin lispro by sliding scale twice daily. During observation on 06/16/2026 at 12:28 p.m., the resident’s insulin was found in the medication room refrigerator with the other insulins, and it had been opened on 05/15/2026. RN B stated the insulin was expired because Humalog has a 28-day shelf life and said it should have been disposed of rather than left in the refrigerator where someone might accidentally use it. ADON A and the DON both stated expired medication should not be in the refrigerator and that nurses were responsible for ensuring there were no expired medications present. The facility’s policy stated that medications past expiration date would be stored separately under lock and key, and the Administrator stated the facility did not have a policy regarding insulin shelf life and would follow the manufacturer’s guideline.
Medication Error Rate Exceeded Threshold Due to Late Administration
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent. Surveyors identified 11 medication administration errors out of 25 opportunities, resulting in a 44.4% error rate for one resident reviewed for medication errors. The deficiency centered on Resident #44, a female with dementia, pleural effusion, drug-induced constipation, GERD, rheumatoid arthritis, hypertension, and anxiety, who also had severe cognitive impairment with a BIMS score of 06 and medically complex conditions. Resident #44’s record showed multiple medications ordered for administration at 8:00 a.m. and 9:00 a.m., including furosemide, lidocaine patch, losartan, metoprolol succinate, Miralax, senna S, ipratropium nasal spray, famotidine, paroxetine, and hydroxychloroquine. During observation, MA D was passing medications in the hall and prepared and administered a total of eleven medications for the resident at 11:37 a.m. When asked, she stated she was preparing the resident’s morning medications and acknowledged she was late. It was observed that the medications were due at 8:00 a.m. and 9:00 a.m., and the resident’s eMAR was in red. During interviews, MA D stated the late administration could be considered a medication error because the eMAR was red, indicating the medications were late. The DON and ADON A both stated that medications were expected to be given within the facility’s two-hour window and that administration outside that timeframe constituted a medication error. The DON also stated that the late medications were unacceptable and that medication errors such as wrong time could cause adverse reactions and worsening of existing conditions. Facility policies reflected that medication error rates were to remain below 5 percent and that drug administration errors could include giving a medication at the wrong time.
Improper Storage of Nebulizer Mask for Resident Receiving Respiratory Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards, the resident’s comprehensive person-centered care plan, and the resident’s goals and preferences for one resident who required respiratory care. The resident was an older female with COPD and acute and chronic respiratory failure with hypoxia, admitted in February 2026. Her comprehensive care plan, dated 02/09/2026, documented COPD, and an intervention added on 02/17/2026 directed staff to provide nebulizer treatments as ordered. A physician’s order dated 02/16/2026 prescribed Ipratropium-Albuterol via nebulizer four times daily for seven days for acute and chronic respiratory failure with hypoxia. On 02/17/2026 at 10:08 AM, surveyors observed the resident lying in bed asleep with a nebulizer on her nightstand and the attached breathing mask not stored in a bag. Multiple staff interviews confirmed that the nebulizer mask should have been stored in a bag when not in use as part of infection control practices. A CNA stated that if the nurse forgot, she could obtain a bag and that she would discard a mask found on the floor and notify the nurse. An RN, the ADON, the Administrator, and the DON each stated that nebulizer masks and other respiratory items were expected to be bagged when not in use, and that nurses were responsible for ensuring this occurred after treatments. The facility did not have a written policy specifically addressing storage of respiratory items when not in use.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Hospice and Parkinson's Disease
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents with significant medical needs. One resident, who was diagnosed with encephalopathy, respiratory failure, kidney disease, and cerebrovascular disease, was admitted to hospice care as indicated by physician orders and the MDS assessment. However, the resident's care plan did not include hospice care, despite documentation and staff acknowledgment of the resident's declining condition and active hospice involvement. Two other residents, both diagnosed with Parkinson's disease and prescribed carbidopa-levodopa, also lacked care plans addressing their primary medical condition. Their diagnoses and medication orders were documented in their records and MDS assessments, but their comprehensive care plans did not reflect interventions or goals related to Parkinson's disease. Staff interviews confirmed that these omissions were oversights and that care plans for these conditions were not created as required. Facility staff, including the MDS nurse, ADON, and DON, acknowledged during interviews that care plans are essential for ensuring all staff are aware of and provide appropriate care for residents' needs. The absence of care plans for hospice and Parkinson's disease was recognized as a failure to document and coordinate necessary care and services, as required by facility policy and regulatory standards.
Failure to Ensure Accident Hazard Prevention and Safe Transfer Practices
Penalty
Summary
Surveyors identified that the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for three residents with a history of falls and severe cognitive impairment. Specifically, these residents were found to have scoop mattresses on their beds without corresponding physician orders or documentation in their care plans. Observations confirmed the presence of the scoop mattresses, and interviews with nursing staff and administration revealed a lack of awareness regarding the requirement for physician orders for such specialty equipment, despite other residents in the facility having appropriate orders. Additionally, the facility failed to ensure that a certified nursing assistant (CNA) used a gait belt when transferring a resident from bed to wheelchair. The CNA manually transferred the resident without a gait belt, despite knowing it was required for safe transfer, citing the absence of a gait belt in the room as the reason. Interviews with nursing staff, the DON, and the administrator confirmed that the use of a gait belt is an established policy and expectation for all manual transfers to prevent resident injury. Record reviews and staff interviews further substantiated that the facility's policies require physician orders for specialty equipment and the use of gait belts during transfers. The lack of adherence to these policies resulted in residents being exposed to potential accident hazards, as evidenced by the observed practices and documentation gaps.
Multiple Lapses in Food Storage and Sanitation Practices
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen and dining areas regarding food storage, preparation, and sanitation. The ice machine in the kitchen had black and white stains inside and along its opening, and the ice scoop holder had gritty stains at the bottom. Another ice machine in the dining area had a buildup of dark brown dirt, and an ice cream machine in the same area had white and brownish stains on its exterior. Additionally, a tea dispenser in the dining area was found uncovered while filled with tea, exposing it to potential air-borne contaminants. Further observations revealed that several food items in the refrigerator, including a bowl of chef salad, bags of pre-scrambled eggs, a pack of cheese, a container of soup, and a plate with fruits, cottage cheese, lettuce, and crackers, were not labeled with storage dates. A large container of fruit cocktail with a past use-by date was not discarded, and a tray of frozen beef patties in the freezer was not properly sealed. The facility's policy requires food to be stored, prepared, and served according to professional standards, with leftovers discarded after 72 hours and expired products removed. Interviews with the Dietary Manager and Administrator confirmed these practices were not followed, acknowledging the potential for cross-contamination and contamination due to these lapses.
Infection Control Lapses During Wound and Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices involving three residents. For one resident with a wound infection and impaired cognition, the Wound Care Nurse did not perform hand hygiene when changing gloves during wound care. The nurse removed soiled gloves and immediately donned clean gloves without using hand sanitizer, despite having access to hand sanitizer in her treatment cart. The nurse acknowledged forgetting to bring the sanitizer into the room and recognized the importance of hand hygiene in preventing infection transmission. In another instance, a CNA transported a bedside table with contaminated linens from a resident's room into the hallway after providing incontinence care. The linens, which had been in the resident's room, were not bagged before being taken out, contrary to facility policy and standard infection control procedures. Both the CNA and other staff interviewed confirmed that linens should have been bagged in the resident's room to prevent cross-contamination, and that bringing potentially contaminated items into the hallway was improper. A third deficiency involved a CNA providing incontinent care to a resident with bladder and bowel incontinence and a skin wound, who was on enhanced barrier precautions. The CNA did not perform hand hygiene before or after care, failed to change gloves after cleaning soiled areas and before handling clean items, and did not wear a gown as required for residents on enhanced barrier precautions. The CNA also did not notice the precaution signage and did not use the available gown in the room. Staff interviews confirmed that these actions were inconsistent with facility policy and infection control standards.
Failure to Maintain Dignity During Resident Feeding
Penalty
Summary
A deficiency was identified when staff failed to honor a resident's right to be treated with respect and dignity during mealtime. Specifically, a certified nursing assistant (CNA) was observed feeding a 38-year-old male resident, who had severe cognitive impairment and required total assistance with activities of daily living, while standing over him as he lay in bed. Both the CNA and the registered nurse (RN) acknowledged that facility policy required staff to be seated at eye level with residents during feeding to promote dignity and facilitate better communication. The resident's care plan also specified that diet should be provided and served as ordered. Interviews with staff, including the director of nursing (DON), confirmed awareness of the expectation to provide one-on-one interaction at eye level during feeding. The facility's policy on feeding residents emphasized the importance of positioning staff at eye level to ensure dignified care. The failure to follow this protocol was observed and confirmed through staff interviews and policy review, resulting in a deficiency related to the resident's right to dignity and respect.
Failure to Ensure Call Light Accessibility for Residents with Cognitive and Physical Impairments
Penalty
Summary
The facility failed to ensure that the call light system was accessible to two residents, both of whom had significant cognitive and physical impairments and were at risk for falls. For one resident, who had moderate cognitive impairment, lack of coordination, and a history of falls, the call light was found wedged between the mattress and bed frame, out of the resident's reach. The resident was unable to identify the location of the call light when asked. Staff interviews confirmed that call lights should be within reach and that staff are responsible for ensuring this before leaving the room. For the second resident, who had severe cognitive impairment, dementia, and a history of falls, the call light was observed on the floor by the bed while the resident was lying awake in bed. The resident did not respond verbally when asked about the call light. Staff confirmed that the call light should be within reach and that it is important for residents to have access to the call system for assistance with personal needs and emergencies. Facility policy requires that the call system be accessible to all residents, including those who are alert, confined, or confused, and specifies that the system should be accessible even to a resident lying on the floor. Despite this policy, observations and interviews revealed that staff did not consistently ensure call lights were within reach for these residents, resulting in a failure to reasonably accommodate their needs and preferences as required.
Failure to Immediately Dispose of Dropped Controlled Medication
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring the immediate and secure disposal of a controlled medication, Lorazepam, prescribed for a resident with severe cognitive impairment and multiple medical conditions, including encephalopathy, respiratory failure, chronic kidney disease, and cerebrovascular disease. The resident was receiving hospice care and had a physician's order for Lorazepam to be administered via a gastrostomy tube as needed for anxiety. During medication preparation, an RN dropped a Lorazepam tablet on the floor but did not immediately pick it up or dispose of it. Instead, the RN prepared a new dose for administration and left the dropped tablet unattended on the floor, out of her sight due to a privacy curtain. The RN completed the medication administration and other tasks before returning to the dropped tablet, at which point she called the ADON to witness its disposal. The tablet was then crushed and disposed of in a sharps container, and the narcotic sheet was co-signed. Interviews with the RN, ADON, DON, and Administrator confirmed that the expectation was for controlled substances to be disposed of immediately and not left unattended, as leaving the medication on the floor could result in unauthorized access or ingestion. The facility's policy required the immediate disposal of contaminated controlled substances, but this procedure was not followed in this instance.
Improper Storage of Topical Medication
Penalty
Summary
A deficiency occurred when a container of zinc oxide cream, prescribed for skin irritation and incontinence care, was left on top of a resident's bedside table rather than being stored in a locked or secured compartment. The resident involved had a history of Alzheimer's disease, delusional disorder, and depression, with moderate cognitive impairment as indicated by a BIMS score of 10. The resident required assistance with incontinence care and was prescribed multiple medications, including antidepressants and hypnotics. There was no documentation indicating that the resident requested the barrier cream be left out, and the facility's policy required all drugs and biologicals, including those for external use, to be stored securely. Observations confirmed that the zinc oxide was accessible to the resident, who was in bed at the time, and staff interviews acknowledged that the cream should not have been left within reach due to the risk of ingestion, especially for residents with cognitive impairment. Staff members, including a CNA, ADON, DON, and the Administrator, all recognized that the cream should have been secured after use, in accordance with facility policy. The failure to properly store the medication was not in line with accepted professional principles and facility policy, as confirmed by both observation and staff statements.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to administer medications as ordered to a resident, specifically Lidocaine HCL at 5% external patch, on multiple occasions in March 2024. The resident, a female with diagnoses including Parkinsonism, asthma, and chronic lower back pain, did not receive her prescribed Lidocaine patches on five separate days. This failure was observed during medication administration and confirmed through interviews with the resident and staff, as well as a review of the resident's medical records and physician orders. The medication aide reported that the Lidocaine patches had been ordered but had not arrived, and this issue was communicated to the nurse in charge. The resident confirmed that she had not received the patches on several days and noted that while her back was stiff, she did not experience pain without the patches. Interviews with the Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON) revealed a lack of awareness and communication regarding the need to reorder the patches and the formulary coverage issues. The DON and the Medical Director were not aware of the inconsistency in administering the Lidocaine patches until the day before the survey. The facility's policy and procedure for ordering and receiving medications were reviewed, indicating that medications should be ordered within 72 hours of the last dose available and discrepancies should be promptly reported. However, these procedures were not effectively followed, leading to the resident not receiving her prescribed medication consistently.
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Illustrative
What surveyors actually found near you
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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 Mesquite
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mesquite Tree Nursing Center | 1.7 mi | ★★★★★ | 11 | 0 |
| Mesquite Village Wellness & Rehabilitation | 2.2 mi | ★★★★★ | 2 | 0 |
| Edgewood Rehabilitation And Care Center | 2.9 mi | ★★★★★ | 2 | 0 |
| Willowbend Nursing And Rehabilitation Center | 3 mi | ★★★★★ | 18 | 0 |
| Town East Rehabilitation And Healthcare Center | 3.4 mi | ★★★★★ | 6 | 1 |
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