CHEYENNE MANOR

The initial comments (ID Prefix Tag # K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is a one-story Type V (000) wood-framed structure without a basement. An addition was added in 2007-2008 to expand the main entrance, main dining room, and kitchen areas. The facility is classified as fully protected by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system. This re-certification survey, conducted on November 14, 2025, was for compliance with the National Fire Protection Association (NFPA) 101 Life Safety Code (2012), Chapter 19, "Existing Health Care Occupancies,” and included an exit conference with the Maintenance Director at the conclusion of the survey.

The facility did not meet the required standards regarding means of egress, as observed during the survey and confirmed through staff interviews. It was determined that the following deficiencies exist:1. Exit signs are not present at the intersection area. 2. The directional indicator arrows for exit signage in C Hall do not point in the correct direction. 7.10.1.3 Exit Door Tactile Signage. Tactile signage shall be provided to meet all of the following criteria unless otherwise provided in 7.10.1.4: (1) Tactile signage shall be located at each exit door requiring an exit sign. (2) Tactile signage shall read as follows: EXIT. (3) Tactile signage shall comply with ICC/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities. Life Safety Code 19.2.10.1. Means of egress shall have signs per section 7.10. The directional indicator shall be outside the Exit legend, not less than 3/8 in. (1cm) from any letter. The directional indicator shall be of a chevron type. The directional indicator shall be identifiable as a directional indicator at a distance of 40 ft. (12.2m). A directional indicator larger than the minimum established in this paragraph shall be proportionately increased in height, width, and stroke. The directional indicator shall be located at the end of the sign for the direction indicated. If code-compliant exit signage is not provided for building egress, this deficient practice could affect all residents, staff, and visitors in the building. The Maintenance Director acknowledged the deficiency of the exit signage during the facility tour.

STANDARD is not met as evidenced by: Through record review during the survey, it was determined that the facility failed to establish a written fire watch procedure per 2012 NFPA 101 Life Safety Code, Section 9.6.1.6. The facility failed to establish a written fire watch procedure in the event the fire alarm system was out of service for more than 4 hours in a 24-hour period. 1. The fire watch procedure does not indicate notification to the Division of Fire Prevention and Control, the authority having jurisdiction. 2. Fire watch rounds must be conducted every 15 minutes. 2012 Life Safety Code 101 section 9.6.1.6* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified. The building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. This deficient practice could affect all residents, staff, and visitors should the fire alarm system be out of service and a fire were to occur. During the facility's record review, the maintenance director acknowledged the need for a written Fire Watch program deficiency.

STANDARD not met: Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system per National Fire Protection Association (NFPA) Standards 13 and Standard 25. Sprinkler heads in walk-in freezers and coolers older than five years must be replaced due to the harsh environment. NFPA 25, 2010 section 5.3.1.1.2* Where sprinklers are subjected to harsh environments, including corrosive atmospheres and corrosive water supplies, on a 5-year basis, either sprinklers shall be replaced or representative sprinkler samples shall be tested. This deficient practice could affect all residents, staff, and visitors in all smoke compartments, should the automatic sprinkler system fail to operate promptly and effectively due to non-code-compliant maintenance. The Director of Maintenance acknowledged the deficiency in the maintenance of the automatic sprinkler system during the facility's records review.

STANDARD is not met: Through record review during the survey, it was determined that the facility failed to establish a written fire watch procedure in accordance with 2012 NFPA 101 Life Safety Code, Section 9.7.5The facility failed to establish a written fire watch procedure in the event the fire sprinkler system was out of service for more than 10 hours in a 24-hour period. 1. The fire watch procedure does not indicate notification to the Division of Fire Prevention and Control, the authority having jurisdiction. 2. Fire watch rounds must be conducted every 15 minutes. 2012 Life Safety 101 Section 19.5.1, 9.7.5, 15.5.2 NFPA Where a required fire sprinkler system is out of service for more than 10 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. This deficient practice could affect all residents, staff, and visitors should the fire alarm or fire sprinkler system be out of service and a fire were to occur. The Maintenance Director acknowledged the lack of a written Fire Watch program during record review of the facility.

STANDARD is not met as evidenced by: Based on observation and staff interview during the tour of the facility, it was determined that the facility failed to maintain the Heating, Ventilating, and Air-Conditioning Systems in accordance with Section 9.2, 19.5.2.1.9.2, NFPA 90A, and 19.5.2.2. The exhaust vent of the clothing dryers in the laundry was disconnected. NFPA 54, Section 10.4.4.2 Ducts for exhausting clothes dryers shall not be assembled with screws or other fastening means that extend into the duct and that would catch lint and reduce the efficiency of the exhaust system. This deficient practice could affect all residents and staff within the facility should a fire emergency occur. The vent deficiencies were discussed with the Maintenance Director during the survey and again during the exit conference.

This standard was not met: Based on observations and staff interviews, it was determined that the facility failed to provide an adequate source of input ratings for appliances operating at elevations above 2,000 feet, in accordance with the National Fire Protection Association (NFPA) Life Safety Code and NFPA 54 Natural Gas Code. The orifices on the clothes dryer are not sized correctly. According to the dryer data plate, they are currently set for 0-2000 feet at a rate of 4 percent for each 1000 ft. (300 m) above sea level. 11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft. (600 m) shall be reduced in accordance with one of the following methods:(1) At the rate of 4 percent for each 1000 ft. (300 m) above sea level, before selecting an appropriately sized appliance.(2) As permitted by the authority having jurisdiction.(3) In accordance with the manufacturer’s installation instructions. This deficiency could impact all residents and staff in the core smoke compartment if the natural gas-fueled heating equipment malfunctions due to improper settings. The deficiencies of the dryer were discussed with the Maintenance Director during the exit conference.

STANDARD is not met, as evidenced by: Through observation during the survey, it was determined that the facility failed to provide no-smoking signs in areas where smoking is prohibited in accordance with NFPA 101 Life Safety Code, Section 19.7.4 (2). IFC 310. No-smoking signs were not posted at all major entrances as required. NFPA 101 19.4.4 Smoking, Smoking regulations shall be adopted and shall include the following provisions: (2) In health care occupancies where smoking is prohibited, and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. IFC 310.3 "No Smoking" signs. The fire code official is authorized to order the posting of "No Smoking" signs in a conspicuous location in each structure or location in which smoking is prohibited. The content, lettering, size, color, and location of required "No Smoking" signs shall be approved. This deficient practice could affect all residents throughout the building if a fire occurs due to smoking. The Director of Maintenance acknowledged the lack of posted signage during the facility tour.

STANDARD not met: Based on record review and documentation of inspection and testing of the non-hospital grade electrical outlets in patient care areas as required by sections 6.3.4.1.3 and 6.3.4.2.1.1 of NFPA 99, Health Care Facilities Code. No written test records of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patients care areas was conducted annually. NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). 6.3.4.1 Maintenance and Testing of Electrical System. 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation orgeneral anesthesia is administered, shall be tested at intervals not exceeding 12 months. 6.3.4.2 Record Keeping. 6.3.4.2.1* General. 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modifications. 6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. This deficient practice could affect all residents, staff, and visitors throughout the facility if the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade were to fail due to a lack of testing. The non-hospital grade electrical outlets testing at the patient’s care areas deficiency was discussed with the Director of Maintenance during the survey.

The facility did not comply with the standards for maintaining emergency power systems as outlined in section 19.2.9.1 of the Life Safety Code and the 2010 NFPA 110, Section 8.3, regarding Maintenance and Operational Testing. At the time of the survey, no records were available to verify the monthly testing and recording of the specific gravity of the batteries related to the emergency power supply system (EPS). NFPA 110, Section 8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted. The failure of the battery testing could potentially impact all residents in the event of a power loss. The emergency power supply system deficiency item was discussed with the Administrator and Maintenance Director during the survey.

A recertification survey was conducted from 10/27/25 to 10/29/25. Three deficiencies were cited.

An emergency preparedness survey was conducted from 10/27/25 to/10/29/25. No deficiencies were cited.

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. Where appropriate due to a mental or physical condition of the complainant or aggrieved party, an oral explanation shall accompany the written ones.” II. Resident #17A. Resident statusResident #17, age greater than 75, was admitted on 9/24/19. According to the October 2025 computerized physician orders (CPO), diagnoses included anxiety, osteoarthritis of the right shoulder and unspecified dementia. The 10/20/25 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment revealed the resident required moderate staff assistance with dressing, transfers, and bathing. B. Resident interviewResident #17 was interviewed on 10/27/25 at 1:45 p.m. Resident #17 said her toilet was too low and she needed a toilet seat riser to use her toilet comfortably. She said she had requested a toilet seat riser from the facility for a few months but had not received one and had reported this grievance at least three times. Resident #17 said she had also filed a grievance about her window blinds that she was unable to close because she could not raise her arms. She said she had requested curtains so she could let light in or block the light. Resident #17 said she had also filed a grievance regarding the activities assistant because the assistant would set up an activity and then leave the activity.-During the interview with Resident #17 in her room, no toilet seat riser or curtains were observed. C. Record reviewThe comprehensive care plan, revised 7/29/25, the resident had complaints of pain in her wrists and hands due to chronic arthritis, right wrist carpal tunnel syndrome and osteoarthritis in both shoulders. Interventions, dated 7/29/25, included providing the resident with one person staff assistance with activities of daily living (ADL). A review of Resident #17's electronic medical record (EMR) failed to reveal documentation indicating Resident #17’s grievances had been addressed. On 10/29/25 at 9:45 a.m., grievances submitted for Resident #17 were requested from the social services director (SSD). The facility was unable to provide any grievances from the resident. III. Staff interviewsThe SSD was interviewed on 10/29/25 at 1:00 p.m. The SSD said the facility’s process for grievances was that when a resident had a grievance, the resident was encouraged to report the concern to the SSD. She said she then would talk to the resident, family, and any staff that were involved and take the concern to the department manager who was responsible for the department pertaining to the grievance. The SSD said depending on the grievance, she would also offer to schedule a meeting with the third party resident advocate. The SSD said she did not use formal grievance forms and the facility did not have specific grievance forms. She said she would type up the details of the resident’s grievance in a word document and save the documentation. She said if another department resolved the grievances, the SSD would include in her word document what the department manager did to resolve the grievance. The SSD said there was no written documentation provided to the resident or complainant and no documentation was signed by the resident or complainant to show a resolution was provided. The SSD said she did not have any written grievances for Resident #17. She said the facility had provided the resident with a new toilet and several different toilet risers, but she said there was no documentation of that. She said she was unaware of any grievances for Resident #17 related to the window or activities. The NHA was interviewed on 10/29/25 at 1:45 p.m. The NHA said the facility did not have a formal grievance process which included grievance forms for complainants to complete and documentation to be provided back with the resolution. She acknowledged the facility needed to improve their process to ensure grievances were documented, responded to timely, and resolved in a satisfactory way for the complainant.

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 75, was admitted on 5/16/24. According to the October 2025 computerized physician orders (CPO), diagnoses included traumatic brain injury, vascular dementia and stroke. The 8/13/25 minimum data set (MDS) assessment revealed Resident #12 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of nine out of 15. The resident required moderate to extensive staff assistance with activities of daily living (ADL) and required a mechanical lift to transfer from the bed, chair, or toilet. Resident #12 had impairments to his right side with a contracture to the right hand related to his stroke. B. Resident and resident’s representative interview Resident #12's spouse was interviewed on 10/28/25 at 2:15 p.m. He said in September 2025, he went to the nurses’ station and certified nurse aide (CNA) #1 was at the nurses’ station with registered nurse (RN) #3. He said when he asked CNA #1 to transfer Resident #12, she ignored him and refused to transfer Resident #12 even after being asked by RN #3. He said CNA #1 used profanity at him when he complained about her not providing care to Resident #12. He said RN #3 had to find another CNA to transfer Resident #12. Resident #12 was interviewed on 10/29/25 at 9:00 a.m. Resident #12 said he did not like the drama between his spouse and the staff. He said he just wanted to go home with his spouse and became emotional. He said he no longer wanted to discuss the incident. C. Record reviewThe ADL care plan, revised 8/19/25, revealed Resident #12 had an ADL deficit related to a stroke and required staff assistance for transfers with a mechanical lift. III. Staff interviewsRN #3 was interviewed on 10/29/25 at 11:08 a.m. RN #3 said on 9/4/25, Resident #12's spouse came to the nurses’ station and asked CNA #1 to transfer Resident #12 from his recliner. RN #3 said that CNA #1 ignored the spouse twice. RN #3 said when the spouse told RN #3 that CNA #1 had ignored him, she asked CNA #1 to go and transfer Resident #12. RN #3 said CNA #1 replied that she was busy charting notes. RN #3 said Resident #12's spouse then became upset and said he was going to report CNA #1. She said CNA #1 responded by using profanities and telling the spouse she did not care what he did and she would do what she wanted. RN #3 said she had to find a different CNA to provide care to Resident #12, because CNA #1 was unwilling to assist. RN #3 said if a caregiver refused to provide care to a resident, that would constitute neglect. She said she reported the incident to the director of nursing (DON) right after she ensured Resident #12 was transferred. CNA #1 was interviewed on 10/29/25 at 12:19 p.m. CNA #1 said that Resident #12's spouse had previously accused her of being mean to the resident and yelling at him, so she would not interact with the spouse any longer. CNA #1 said that when the spouse would come into the facility, he would direct her to do things for the resident. She said she was aware of her responsibilities, therefore she would ignore him. She said she felt after he made accusations against her, she had the right to not respond to him. CNA #1 said that she did not have to speak to anyone that she did not want to speak to and she had the right to choose to ignore him when he spoke toher. She said on the day of the incident, the spouse had come to the nurses’ station demanding that she transfer Resident #12 and she told the nurse she would transfer the resident. CNA #1 said she did ignore the spouse initially, but after being asked by the nurse, she went to complete the transfer. -However, according to interviews with, RN #3 and the DON two other CNAs completed the transfer, because CNA #1 refused to provide assistance. CNA #1 said there was never an investigation done against her, nor at any time was she ever suspended or removed from providing care to Resident #12. The social services director (SSD) was interviewed on 10/29/25 at 1:00 p.m. She said the facility's process for investigating potential resident abuse included interviewing other residents to determine if they had experienced anything similar to the allegation, interviewing all the employees present along with any other employees that may have worked in the same area and suspending the employee alleged in the abuse. The SSD said the reason for suspending any employees that had been named in an abuse allegation was to ensure the resident’s safety and that no retaliation would occur. The SSD said the definition of caretaker neglect was not giving the resident care to ensure their well-being and safety. The SSD said if an employee refused to provide care to a resident, that would constitute caretaker neglect. The SSD said she had not been notified of CNA #1 refusing to provide care to Resident #12. She said if she had been notified, she would have investigated the incident as potential abuse to determine if CNA #1 had refused to care for any other residents. She said using profanity at a family member and refusing to provide care was not a customer service issue but potential neglect of a resident's needs. The NHA and the DON were interviewed together on 10/29/25 at 1:45 p.m. The DON said that staff received abuse training during their onboarding and annually. She said examples of caregiver neglect included ignoring call lights, not providing care that was needed and not responding to a resident's needs. The DON said if a caregiver responded to a write-up or a complaint by lashing out or not taking care of the resident involved, this would be considered retaliation. The DON said there had been a build up of negativity between CNA #1 and Resident #12's spouse. The DON said the two did not get along. She said on 9/4/25, the spouse came to the front desk and asked CNA #1 for assistance transferring Resident #12. The DON said CNA #1 did not respond to him. The DON said when the spouse told her he was going to file a compliant, CNA #1 began using profanity and told him she did not care what he did. She said two other CNAs went to assist Resident #12. The DON said CNA #1 had told her that she did not want to have contact with the spouse because of disagreements the two have had in the community outside of the facility. The DON said CNA #1 expressed she did not want anything to do with the spouse. She said CNA #1 was never suspended, investigated, or removed from Resident #12's hall. The DON said the potential impact of CNA #1 refusing to respond to Resident #12's spouse when he requested care for the resident was that the resident may not receive care or his care may be delayed. The NHA said the facility's process when suspected abuse of any kind occurred was to suspend the potential staff involved, interview other staff and interview other residents that the staff member may have been providing care for. She said after the disciplinary write up on 9/4/25 with CNA #1, the facility checked in with Resident #12 to ensure he was receiving care from CNA #1. The NHA said the facility also checked in with the staff. She said there had not been an investigation regarding the incident on 9/4/25. The NHA said the staff and other residents were not interviewed to determine if this was a pattern or if there had been other potential victims, because she had viewed the incident as a customer service issue. The NHA said the refusal to provide care should have been treated as potential neglect and the facility should have conducted an investigation.

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. Performance expectations are set with employees and measured throughout the year. "Performance Evaluation process is designed to help managers and their employees define their objectives and goals that align with the Mission, Vision, and Values of Cheyenne Manor. Performance results are highlighted in the process and areas of development will include guidance for improvement. "All employees are provided an annual performance review and consideration for merit pay increases as warranted."Performance reviews are done on an annual basis. In addition to the annual review, a supervisor may initiate a Performance Improvement Plan (PIP) if deterioration in performance has taken place or if the employee needs additional, specific direction.“Evaluations are performed by immediate supervisors. Performance reviews allow employees an opportunity to provide input as part of the performance process."II. Record reviewAnnual performance reviews were requested on 10/28/25 at 10:10 a.m. for CNA #1 (hired 3/12/12), CNA #3 (hired 4/24/24), CNA #4 (hired 4/12/23), CNA #5 (hired 11/17/1998) and CNA #6 (hired 2/8/07).-The facility was unable to provide documentation indicated CNA #1, CNA #3, CNA #4, CNA #5 and CNA #6 had annual performance evaluations. The NHA said the five CNAs did not have annual performance reviews and had not completed annual in-service education based on the outcome of their reviews. III. Staff interviewThe NHA was interviewed on 10 /28/25 at 2:29 p.m. The NHA said the facility did not conduct annual performance reviews. She said the CNA raises were based on the cost of living and decided by the board of directors. She said performance evaluations were not conducted and regular in-service education based on the outcome of the reviews was not provided.

The initial comments (ID Prefix Tag # K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is a one-story Type V (000) wood framed structure without a basement. An addition was added in 2007-2008 to expand the main entrance, main dining room and kitchen areas. The facility is classified as a fully protected by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system. This re-certification survey conducted on May 07, 2024 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies". An exit conference with the Administrator, Maintenance Director at the conclusion of the survey. This Inspector found no violationsNo Action Required

A recertification survey was conducted from 4/22/24 to 4/25/24. No deficiencies were cited.

An Emergency Preparedness survey was conducted from 4/22/24 to 4/25/24. No deficiencies were cited.

A revisit survey was completed on 3/9/23 for all previous deficiencies cited on 12/21/22. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 3/9/23 for all previous deficiencies cited on 12/21/22. The facility is in compliance with all regulations surveyed.