Federal inspectors found Cody Regional Health Long Term Care Center failed to offer meal choices to residents in both dining rooms during their April visit.
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The resident, identified as R7, was admitted to hospice services on February 26 with a terminal diagnosis of senile degeneration of the brain.
But no warning sign was posted on the door to alert other staff entering the room.
The April inspection at El Dorado Care and Rehab found Resident 48 positioned at her bedside table at 9 a.m., ready for her morning meal.
"The facility did not have a restorative nurse and RI #60 was not being followed by an FMP," the Director of Therapy told inspectors on April 7.
The April 2026 inspection revealed that workers were not consistently reviewing resident profiles to determine appropriate transfer methods.
Federal inspectors found food storage violations on every floor of the University Avenue facility during their April 7-9 visit.
When residents develop new mental health conditions, facilities must update these screenings to ensure they receive appropriate care.
Federal inspectors found the facility failed to provide bathing on scheduled days for two of four residents they reviewed during an April inspection.
Resident #7 presented the starkest contradiction.
The readings included levels low enough to cause unconsciousness and high enough to trigger diabetic coma.
The facility's own policy required staff to reassess every resident within two to three days of starting antibiotics.