Life Care Center Of Cheyenne

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Based on observation, medical record review, and staff and resident interview, the facility failed to promote and facilitate resident choice and preferences for 1 of 2 sample residents (#12) reviewed. The findings were:1. Review of the 7/21/25 admission MDS assessment showed resident #12 had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included cancer, malnutrition, frequent pain, rheumatoid arthritis and muscle weakness. Further review showed the resident had major surgical procedures prior to admission to the facility which involved placement of nephrostomy tubes and a colostomy. The following concerns were identified: a. Observation on 9/24/25 at 2:31 PM showed RN #1 was changing the resident's dressings following a shower. The resident was lying in his/her bed with his/her upper body exposed and was visibly shivering. The resident verbalized that s/he was cold and CNA #1 offered to turn up the heat. RN #1 responded stating Please don't right now. RN #1 was observed wearing PPE (personal protective equipment), which included a gown and stated she was hot and would require a shower following the dressing change. b. Interview with resident #12 on 9/24/25 at 11:20 AM confirmed that s/he was cold during the dressing change and would have preferred the heat be increased while the dressing was changed.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Cheyenne

1330 Prairie Ave Cheyenne, WY 82009

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645

PASARR screening for Mental disorders or Intellectual Disabilities

Level of Harm - Minimal harm or potential for actual harm

Based on staff interview and medical record review, the facility failed to ensure a Level II PASRR (preadmission screening and resident review) evaluation was completed prior to admission for 1 of 1 residents (#123) reviewed. The findings were: 1. Review of the 8/20/25 admission MDS assessment showed resident #123 had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included bipolar disorder, anxiety disorder and cerebrovascular accident, transient ischemic attack, or stroke. The following concerns were identified: a. Review of the resident's PASRR Level I, dated 8/14/25, showed evidence of a mental illness which required a PASRR Level II screening prior to admission to the facility. Further review of the resident's medical record showed no evidence a PASRR Level II evaluation had been completed. 2. Interview with the NHA on 9/15/25 at 9:40 AM confirmed a PASRR Level II was not completed prior to admission.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Cheyenne

1330 Prairie Ave Cheyenne, WY 82009

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697

Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, policy and procedure review, medical record review, and resident and staff interview,

the facility failed to ensure effective pain management was provided to 1 of 4 residents (#12) reviewed for pain management. The findings were: 1. Review of the 7/21/25 admission MDS assessment showed resident #12 had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included cancer, frequent pain, rheumatoid arthritis and muscle weakness. Further review showed the resident had major surgical procedures prior to admission to the facility which involved placement of nephrostomy tubes and a colostomy. Review of the September 2025 medication administration record showed the resident was last administered 5 milligrams (mg) of oxycodone on 9/24/25 at 7 AM for a pain rating of 7 out of 10 and 500 mg of acetaminophen was administered on 9/23/25 at 9 PM. The following concerns were identified: a. Observation on 9/24/25 at 2:31 PM showed RN #1 was preparing dressing change supplies for resident #12 which was to be completed following the resident's scheduled shower with occupational therapy. RN #1 with the assistance of NP #1 and CNA #1 began changing the resident's colostomy bag and wafer as well as his/her nephrostomy tube dressings. Further

observation showed the resident was rolled from side-to-side and verbalized back pain as well as discomfort to the adhesive sites of the wafer and dressings. In addition, RN #1 did not assess or acknowledge the resident's pain complaints prior to or during the dressing change. b. Observation on 9/24/25 at 3:10 PM showed RN #1 assessed the resident's pain level and determined it to be 8 to 9 out of 10 and administered prescribed Tylenol per the resident's request at 3:22 PM. c. Interview with RN #1 on 9/24/25 at 3:54 PM revealed the resident was premedicated for pain prior to dressing changes on occasion.

Further, the RN stated The resident's pain and anxiety is so bad at times that we will just push through it. d.

Interview with the DON on 9/24/25 at 3:58 PM revealed residents who have known pain with dressing changes were pre-medicated if it was within the physician's ordering timeframe. e. Review of the physician's orders showed 500 mg of acetaminophen every 6 hours as needed was ordered on 9/11/25 and 5 mg of oxycodone every 6 hours for moderate to severe pain was ordered on 9/19/25. Further review of physician orders, dated 9/15/25 at 6 AM showed the resident's acceptable pain level was 5 out of 10. f. Interview on 9/25/25 at 11:20 AM with the resident confirmed s/he was in pain during the dressing change and would have preferred to be pre-medicated prior to the procedure. 2. Review of the facility policy titled Pain Assessment and Management, last revised on 9/23/25, showed the facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management while identifying target signs and symptoms, including verbal and non-verbal indicators of pain.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Cheyenne

1330 Prairie Ave Cheyenne, WY 82009

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, staff interview, and review of policy and procedures and standards of practice, the facility failed to ensure effective infection prevention practices were implemented during one random

observation of linen transportation. The census was 119. The findings were: 1. Observation on 9/22/25 at 2:11 PM showed an unidentified staff member was walking down the rehabilitation hall with unbagged soiled towels in her ungloved hands and was transporting them to the soiled linen room. 2. Interview with

the infection prevention coordinator on 9/25/25 at 11:56 AM revealed soiled linen should be bagged before removing them from the residents' room and remain bagged while being transported to the laundry room. 3.

Review of the Centers for Disease Control and Prevention standards of practice titled Laundry and Bedding, last revised 1/08/24, showed soiled laundry should be bagged prior to transporting to the soiled linen room. 4. Review of the facility policy titled Infection Prevention and Control Program (IPCP) and Plan, last revised 6/02/25, showed personnel must handle, store, process, and transport linens so as to prevent

the spread of infection.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet