Life Care Center of Cheyenne: Pain Management Failures - WY
The resident, who was cognitively intact with a BIMS score of 13 out of 15, had undergone major surgical procedures before admission that included placement of nephrostomy tubes and a colostomy. Their diagnoses included cancer, frequent pain, rheumatoid arthritis and muscle weakness.
On September 24, 2025, inspectors observed RN #1 preparing supplies for the resident's dressing change following a scheduled shower with occupational therapy. The nurse, assisted by a nurse practitioner and certified nursing assistant, began changing the resident's colostomy bag and wafer as well as nephrostomy tube dressings.
During the procedure, staff rolled the resident from side-to-side. The resident verbalized back pain and discomfort at the adhesive sites of the wafer and dressings. RN #1 did not assess or acknowledge the resident's pain complaints before or during the dressing change.
Forty minutes later, at 3:10 PM, RN #1 finally assessed the resident's pain level and determined it to be 8 to 9 out of 10. The nurse administered prescribed Tylenol at 3:22 PM, but only after the resident requested it.
When inspectors interviewed RN #1 at 3:54 PM, the nurse revealed that while the resident was sometimes premedicated for pain before dressing changes, this didn't always happen. "The resident's pain and anxiety is so bad at times that we will just push through it," RN #1 told inspectors.
The Director of Nursing confirmed that residents with known pain during dressing changes should be premedicated if it falls within the physician's ordering timeframe. The facility had clear physician's orders for both 500 mg of acetaminophen every six hours as needed, ordered September 11, and 5 mg of oxycodone every six hours for moderate to severe pain, ordered September 19.
Physician orders from September 15 established the resident's acceptable pain level at 5 out of 10. Yet medication records showed the resident's last dose of oxycodone was administered on September 24 at 7 AM for a pain rating of 7 out of 10, and acetaminophen was last given on September 23 at 9 PM.
The resident confirmed the painful experience when inspectors interviewed them the following day. The resident was in pain during the dressing change and would have preferred to be premedicated prior to the procedure.
This violation occurred despite the facility's own pain management policy, revised just one day before the inspection on September 23, 2025. The policy requires that residents receive treatment and care in accordance with professional standards of practice and the resident's choices related to pain management. It mandates identifying target signs and symptoms, including verbal and non-verbal indicators of pain.
The facility's failure to follow its own protocols meant a cancer patient who had already endured major surgeries was subjected to additional unnecessary suffering during routine medical care. Federal inspectors classified this as a violation with minimal harm or potential for actual harm, affecting few residents.
The resident's experience illustrates how inadequate pain management protocols can compound the suffering of vulnerable nursing home residents who depend on staff to advocate for their comfort during medical procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of Cheyenne from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Life Care Center of Cheyenne in Cheyenne, WY was cited for violations during a health inspection on November 18, 2025.
Their diagnoses included cancer, frequent pain, rheumatoid arthritis and muscle weakness.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.