Cody Regional Health Long Term Care Center

Based on observation, resident and staff interview, and menu and alternative menu review, the facility failed to consider resident preferences for meals in 2 of 2 dining rooms (main dining room, 2nd floor dining room). The census was 51. The findings were:1. Interview with resident #7 on 4/6/26 at 4:05 PM revealed residents were not offered choices for meals and they get what is served. S/he revealed residents could choose an alternative sandwich to eat if they did not want the main meal. 2. Interview with resident #36 on 4/6/26 at 4:41 PM revealed s/he did not feel she could make choices at the facility and there were not alternative meal options given if s/he did not like the food. 3. Observation of meal service in the second-floor dining room on 4/6/26 at 5:02 PM showed the white board indicated the dinner was a turkey and cheddar wrap with lettuce, tomato, and onion, garlic Brussel sprouts, and banana cream pie. There was no evidence of an alternative meal item listed. Interview with dietary staff member #1 at that time revealed if residents did not want the meal, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure adequate monitoring of psychotropic medications for 5 of 5 sample residents (#2, #4, #5, #41, #56) reviewed for unnecessary medications. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #41 had a BIMS score of 11 out 15, which indicated moderate cognitive impairment, and diagnoses which included anxiety disorder and depression. Further review showed the resident displayed no behaviors and received antidepressant and hypnotic medication. Review of the physician orders showed the resident received temazepam (hypnotic) 7.5 milligrams (mg) by mouth daily at bedtime for insomnia and duloxetine (antidepressant) 40 mg by mouth twice per day for major depressive disorder. Review of the antidepressant medication care plan, last revised on 3/31/26 showed interventions which included Monitor/Document side effects and effectiveness Q [every] shift. The following concern was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, resident and staff interview, and grievance log review, the facility failed to ensure reasonable care for the protection of the resident's property from loss or theft for 1 of 4 sample residents (#31) reviewed for missing items. The findings were:1. Interview with resident #31 on 04/06/26 at 4:51 PM revealed s/he stated concerns of a missing short fuchsia colored jacket s/he had only one day and it's been missing since then. The resident stated s/he had mentioned it at the last care plan meeting and nothing had been done.2. Review of a progress notes for resident #31 dated 1/23/26 and timed 2:28 PM showed Per CNA resident refused [his/her] bath and stated I will not take a bath until my purple magnetic jacket is found. Staff has been looking for jacket and laundry has been notified.3. Interview with the SSD on 4/9/26 at 10:38 AM revealed she was not aware of a fuchsia jacket that was missing from resident #31. She stated when clothing went missing the process was to notify laundry.4. Review of the grievance log for the past year revealed no grievances…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, resident record review, staff interview, professional standard review, and policy and procedure review, the facility failed to ensure administered resident medications were taken in the presence of nursing staff for 1 of 2 resident units (200 unit). The census was 58. The findings were: 1. Observation on 8/19/24 at 5:22 PM showed resident #30 had a medication cup, with medications in it, on the table in front of the resident. Further, observation showed no nurse was present. The resident revealed LPN #1 had dropped it off. 2. Observation on 8/19/24 at 5:55 PM showed resident #47 had a medication cup, with medications in it, sitting in front of resident in dining room. Further, observation showed RN #1 reminded the resident, at 6 PM, to take medication. The RN stated she thought the resident took the medication. 3. Interview with the DON on 8/21/24 at 9:30 AM revealed neither resident was assessed for self-administration of medication and they were not to self-administrator medications. 4. Review of the policy and procedure titled Medication Processing and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, resident record review, staff interview, and policy and procedure review, the facility failed to ensure nursing staff dispensed resident medications according to facility policy and procedure for 1 of 2 resident units (200 unit). The census was 58. The findings were: 1. Observation on 8/19/24 at 5:22 PM showed resident #30 had a medication cup, with medications in it, on the table in front of the resident. Further, observation showed no nurse was present. The resident revealed LPN #1 had dropped it off. 2. Observation on 8/19/24 at 5:55 PM showed resident #47 had a medication cup, with medications in it, sitting in front of resident in dining room. Further, observation showed RN #1 reminded the resident, at 6 PM, to take medication. The RN stated she thought the resident took the medication. 3. Interview with the DON on 8/21/24 at 9:30 AM revealed neither resident was assessed for self-administration of medication and they were not to self-administrator medications. 4. Review of the policy and procedure titled Medication Processing and Administration provided…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to ensure care plans were developed and implemented for 1 of 2 sample residents (#34) observed during personal care. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #34 had a BIMS score of 7 out 15, which indicated severe cognitive impairment, and diagnoses which included renal insufficiency, neurogenic bladder, hypertensive chronic kidney disease, history of traumatic brain injury, and benign prostatic hyperplasia with lower urinary tract symptoms. Further review showed the resident had an indwelling catheter and was dependent on staff for toileting hygiene, personal hygiene, and chair/bed-to-chair transfer. Review of the enhanced barrier precautions care plan initiated on 4/23/24 showed interventions which included .Staff will perform proper donning and doffing of PPE guidelines . The following concerns were identified: a. Observation on 8/21/24 at 10:27 AM showed the resident was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy and procedure review, the facility failed to ensure infection prevention practices were implemented for 2 of 2 sample residents (#18, #34) observed during personal care. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #18 had a BIMS score of 11 out 15, which indicated moderate cognitive impairment, and diagnoses which included hemiplegia or hemiparesis, non-Alzheimer's dementia, and weakness. Further review showed the resident was dependent on staff for toileting hygiene, dressing, and personal hygiene. Review of the ADL self-care performance deficit care plan last revised on 6/12/24 showed interventions which included . [resident name] requires total assist with a full lift for toileting and incontinence care. [s/he] wears a full brief . and . [resident name] is totally dependence [sic] by 1 staff with personal hygiene . The following concerns were identified: a. Observation on 8/21/24 at 10:14 AM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, incident log review, and incident investigation review the facility failed to ensure basic life support and advance directives were followed in 1 of 5 sample residents (#1) reviewed for advance directives. Corrective measures were implemented by the facility prior to the survey and compliance was determined to be met on [DATE]. The findings were: 1. Review the admission minimum data set (MDS) assessment dated [DATE] showed resident #1 had a brief interview for mental status (BIMS) score of 12 out of 15, which indicated moderate cognitive impairment, and diagnoses which included medically complex conditions, atrial fibrillation or other dysrhythmias, pneumonia, depression, respiratory failure, and anxiety disorder. Review of a provider comprehensive 30 day note dated [DATE] and timed 10:52 AM showed .Code status: Full Code . [S/he] was admitted [DATE] - [DATE] for sepsis due to multifocal community-acquired pneumonia (CAP) with acute hypoxic respiratory failure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, review of the US Food Code, and policy and procedure review, the facility failed to ensure the food storage equipment was maintained in a clean and sanitary manner in 1 of 1 kitchens. The census was 52. The findings were: 1. Observation on 7/11/23 at 7:04 AM showed the top of the Blodgett oven, Rational Self-Cooking Center, and the Metro c5 1 series proofing cabinet were soiled with dark discolored dust and grime. Further observation showed extra racks were stored on top of the rational self-cooking center and a cookie sheet was stored on top of the Blodgett oven, and had discolored dust and grime on them. 2. Observation on 7/13/23 at 10:53 AM showed the top of the Blodgett oven, Rational Self-Cooking Center, and the Metro c5 1 series proofing cabinet remained soiled with dark discolored dust and grime. Further observation showed the extra racks remained on top of the rational self-cooking center and a cookie sheet remained on top of the Blodgett oven, and continued to have discolored dust and grime on them. 3. Interview with the executive chef…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure baths or showers were provided routinely for 1 of 6 sample residents (#109) who required assistance with ADLs. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #109 admitted to the facility on [DATE], had a brief interview for mental status score of 13 out 15 (which indicated the resident was cognitively intact), and diagnoses which included atrial fibrillation, coronary artery disease, heart failure, hypertension, arthritis and osteoporosis. The following concerns were identified: a. Review of the ADL self-care performance care plan last revised on 4/19/23 showed the resident required limited assistance by 1 staff person with bathing/showering as necessary. Further review showed no indication of the resident's bathing preferences related to the frequency of bathing. b. Review of the progress notes showed the resident discharged from the facility on 4/21/23 c.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of medical records, staff interview and policy review, the facility failed to ensure a monthly medication regimen review was performed by a licensed pharmacist at least once monthly for 1 of 5 sample residents (#8) reviewed for unnecessary medications. The findings were: 1. Review of the electronic health records for resident #8 showed there was no evidence a monthly medication regimen review was performed for the months of April 2023 and June 2023. 2. Interview with the director of pharmacy on 7/13/23 at 8:29 confirmed the monthly medication regimen review was not completed for resident #8 during April 2023 or June 2023 and the medication regimen review should be completed monthly. 3. Review of the policy and procedure titled Medication Regimen Review (MRR) Pharmacy provided by the facility on 7/13/23 showed .A pharmacist will perform a medication regime review and clinical review on each Long Term Care resident at the time of the resident's admission to the facility, at least monthly, and when requested by facility staff or attending/consulting provider .

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure medications were properly labeled to include expiration dates for 1 of 2 medication storage areas (second floor medication cart). The findings were: 1. Observation on 7/12/23 at 2:26 PM showed a bottle of Carbidopa/levodopa (decarboxylase inhibitor) 25-100 milligrams (mg) capsules and a bottle of hydrochlorothiazide (diuretic) 25 mg tablets for resident #52 did not have expiration dates. Interview with LPN #1 and RN #1 at that time confirmed neither bottle had an expiration date and revealed both medications were being administered to the resident from the bottles. 2. Interview with the administrator on 7/13/23 at 4:06 PM revealed the facility expected the admitting nurse and pharmacist to verify the medication bottles, brought to the facility by residents had proper labels before the medications were administered. 3. Review of the policy titled Medication Processing and Administration, provided by the facility on 7/13/2023, showed .c) Labeling requirements for medication for LTCC…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure appropriate infection prevention practices during observations of care for 1 of 8 sample residents (#35). The findings were: 1. Observation on 7/12/23 at 3:12 PM showed LPN #1 and RN #1 entered the room of resident #35. At 3:13 PM, LPN #1 exited the room wearing gloves and holding her hands at shoulder height. The LPN walked down the hallway to the nurse's station, without touching items in the hall, and encountered a CNA. The CNA obtained a measuring tool from the nurse's station and walked with the LPN to the resident's room. Upon reentry to the resident's room, RN #1 assisted the resident to roll to his/her right side and the LPN lowered the resident's brief. The LPN used the measuring tool to measure a small open area near the resident's coccyx. At that time, the LPN touched the resident's skin with her gloved hands and manipulated the measuring device and the resident's skin, to obtain wound measurements. When she finished measuring the area and without changing gloves, the LPN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.