Cheyenne Manor

In the surveyor’s words

From the most serious findings on record at Cheyenne Manor, in the surveyor’s own words.

• Actual harm, isolatedF684Dec 21, 2022

  Based on record review and interviews, the facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#2) of three residents reviewed for quality of care of six sample residents. Resident #2 had a diagnosis of type 2 diabetes and was at risk for skin impairment to his feet according to his plan of care. The resident had skin impairments noted to his toe on 4/1/22 indicated by certified nurse aides identified during bathing. The resident had weekly skin assessments which identified reddened, and scabbed areas on both of his feet as early as 4/21/22. […]

• No harm, potential for more than minimal, widespreadF730Oct 29, 2025

  Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for five of five certified nurse aides (CNA).Specifically, the facility failed to complete annual performance reviews for CNA #1, CNA #3, CNA #4, CNA #5 and CNA #6 in order to determine potential training needs. Findings include:I. Facility policy and procedureThe Performance Evaluation policy, undated, was provided by the nursing home administrator (NHA) on 10/28/25 at 3:51 p.m. It read in pertinent part, The performance evaluation process provides a means for discussing, planning and reviewing the performance of each employee. […]

• No harm, potential for more than minimal, patternF580Dec 21, 2022

  Based on record review and interviews, the facility failed to inform the physician and the resident's legal representative of changes in condition with two (#1 and #2) out of three residents out of six sample residents. Specifically, the facility failed to: -Notify the physician for Resident #2 and Resident #1 when their was a change in condition; and, -Notify the resident representative of a change in condition for Resident #2. Findings include: I. Facility policy and procedure The Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated 3/14/11, was provided by the director of nursing (DON) on 12/7/22 at 2:00 p.m. The policy read in pertinent part, under cause identification, 1. […]

• No harm, potential for more than minimal, isolatedF585Oct 29, 2025

  Based on record review and interviews, the facility failed to maintain a system of documenting grievances and demonstrating prompt action for one (#17) of four residents reviewed for grievances out of 17 sample residents. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to individual grievances for Resident #17.Findings include:I. Facility policy and procedureThe Grievance policy, undated, was provided by the nursing home administrator (NHA) on 10/29/25. It read it pertinent part, The person designated to resolve complaints will confer with persons involved in the incident and other relevant persons within three days of the grievance and shall provide a written explanation of the findings and proposed remedies to the complainant. […]

• No harm, potential for more than minimal, isolatedF610Oct 29, 2025

  Based on record review and interviews, the facility failed to ensure one (#12) of three residents reviewed for abuse out of 17 sample residents were free from abuse. Specifically, the facility failed to protect Resident #12 from caregiver neglect when a staff member refused to provide the resident care.Findings include:I. Facility policy and procedureThe Resident Abuse policy, undated, was provided by the nursing home administrator (NHA) on 10/27/25 at 12:21 p.m. It read in pertinent part, During an active investigation any employee who is an 'alleged perpetrator' will be immediately suspended without pay and sent home until an investigation is completed. II. Resident #12A. Resident statusResident #12, age [AGE], was admitted on [DATE]. […]