Cycle 1
Health 2024-08-22 · Fire 2024-08-22
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cody, WY
Cody Regional Health Long Term Care Center
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
707 Sheridan Ave, Cody, WY
(307) 578-2434
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
94
Certified beds
Average residents
49
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1985-01-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.61
Registered nurse staffing · state 0.90 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.48 · national 0.87
Aide hours / resident day
2.59
Nurse aide staffing · state 2.46 · national 2.35
Total nurse hours
3.96
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.48
Weekend nurse staffing · state 3.30 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.62 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
4.73
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
69%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 53% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,687
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9853
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.11
Baseline 55.74% · Performance 50.98% · Measure score 3.11 · Achievement 3.11 · Improvement 1.04
Adjusted total nurse staffing
2.70
Baseline 4.16 hours · Performance 3.85 hours · Measure score 2.70 · Achievement 2.70 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.59% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 3.85% · Lower 95% interval 6.36% |
| Discharge to community | 34.6% |
50.57%
16 pts worse
|
Worse than the National Rate · Eligible stays 45 · Observed rate 26.67% · Lower 95% interval 23.83% |
| Medicare spending per beneficiary | 0.58 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 12 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 79 |
| Staff flu vaccination coverage | 60.5% |
42%
18.5 pts better
|
Numerator 144 · Denominator 238 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.3
0.1 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.5 |
2.2
1.3 pts worse
|
1.8
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 2.9 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.3% |
94.3%
11 pts worse
|
93.4%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 71.7% · Q2 88.9% · Q3 86.3% · Q4 86.3% · 4Q avg 83.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.8% |
94.3%
0.5 pts better
|
95.5%
0.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
4.8%
1.5 pts better
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 5.6% · Q3 0.0% · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
6.4%
4.8 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 6.7% · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
6.5%
1.1 pts better
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 2.1% · Q3 0.0% · Q4 9.1% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.4% |
16.1%
5.7 pts better
|
19.6%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 8.0% · Q3 8.5% · Q4 15.6% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.3% |
24.1%
15.8 pts better
|
16.7%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 4.7% · Q3 7.5% · Q4 15.4% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.9% |
18.5%
3.4 pts worse
|
16.3%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q3 17.3% · Q4 20.6% · 4Q avg 21.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.1% |
18.7%
4.4 pts worse
|
14.9%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 27.1% · Q3 30.4% · Q4 20.9% · 4Q avg 23.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 8.1% |
1.9%
6.2 pts worse
|
1.0%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 8.9% · Q3 6.2% · Q4 6.9% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.9% |
3.0%
3.9 pts worse
|
1.7%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 3.8% · Q3 4.1% · Q4 10.0% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.5% |
23.6%
0.9 pts worse
|
19.8%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 26.0% · Q3 26.0% · Q4 25.6% · 4Q avg 24.5% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
5.0%
0.6 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 5.8% · Q3 6.0% · Q4 8.7% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 22.9% |
75.7%
52.8 pts worse
|
81.7%
58.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 22.9% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.6%
1.6 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-13 · Fire 2023-07-13
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2022-09-29 · Fire 2022-09-29
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2026-01-13
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2026-01-30
F · Potential for more than minimal harm
2024-08-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-10
F · Potential for more than minimal harm
2023-07-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-07-13
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-07-13
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-08-04
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-08-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-09-10
E · Potential for more than minimal harm
2024-08-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-08-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-02-06
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-02-06
F · Potential for more than minimal harm
2023-07-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-04
D · Potential for more than minimal harm
2023-07-13
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-04
D · Potential for more than minimal harm
2023-07-13
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-08-04
D · Potential for more than minimal harm
2023-07-13
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-08-04
D · Potential for more than minimal harm
2023-07-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-04
E · Potential for more than minimal harm
2022-09-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-29
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-10-28
Penalties and ownership
What sits behind the stars
Ownership
West Park Hospital District
5% Or Greater Direct Ownership Interest · Organization
Deiter Enright, Tarra
Operational/Managerial Control · Individual
Mcrae, Mary
Operational/Managerial Control · Individual
Mcrae, Mary
Corporate Officer · Individual
Moore, Laura
Operational/Managerial Control · Individual
Nelson, Richard
Corporate Director · Individual
Talich, Jennifer
Operational/Managerial Control · Individual
West Park Hospital District
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Powell Valley Care Center
Powell, WY
2-star overall rating with 2-star inspections with abuse icon flag with $40,390 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
New Horizons Care Center
Lovell, WY
4-star overall rating with 3-star inspections with $20,450 in total fines with 5 recent health deficiencies
#3
Wyoming Retirement Center
Basin, WY
2-star overall rating with 2-star inspections with abuse icon flag with $41,201 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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