Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Medical Lodge during CMS and state inspections, most recent first.
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.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 999 citations issued within 25 miles in the last 12 months — including the 40 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 12 | 0 |
| Mesquite Village Wellness & Rehabilitation | 2.2 mi | ★★★★★ | 6 | 0 |
| Edgewood Rehabilitation And Care Center | 2.9 mi | ★★★★★ | 2 | 0 |
| Willowbend Nursing And Rehabilitation Center | 3 mi | ★★★★★ | 19 | 0 |
| Town East Rehabilitation And Healthcare Center | 3.4 mi | ★★★★★ | 18 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Cheyenne Medical Lodge.
100% money-back within 48 hours.
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.