Deficiency Records for Cody Regional Health Long Term Care Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Cody Regional Health Long Term Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-07-13 | 2023-08-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-07-13 | 2023-08-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-13 | 2023-08-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-13 | 2023-08-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-13 | 2023-08-04 | Y |
| Meet other general requirements. | Fire Safety | 2023-07-12 | 2023-08-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-12 | 2023-08-04 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-07-12 | 2023-08-04 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-09-29 | 2022-10-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-29 | 2022-10-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-26 | 2021-11-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-26 | 2021-10-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-26 | 2021-10-01 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-08-26 | 2021-09-25 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-08-26 | 2021-09-24 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-08-26 | 2021-09-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-26 | 2021-09-24 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-08-26 | 2021-09-24 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-08-26 | 2021-09-24 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-08-26 | 2021-09-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-26 | 2021-09-24 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-08-26 | 2021-09-10 | N |
