Cotton Point Living Center

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain sanitary conditions for ice intended for resident consumption. The facility failed to ensure the ice machine drain line maintained a required air gap (empty space that ensures dirty sewer water can never flow backward into the ice machine and contaminate the ice) to prevent potential contamination, failed to maintain sanitary conditions surrounding the ice machine, and failed to prevent contamination of communal ice during resident use. These deficient practices had the potential to affect all residents who consumed ice from the facility ice machine. The facility census was 47. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide restorative services for one resident (Resident #9) out of two sampled residents and one resident (Resident #17) outside the sample. The facility census was 47. Review of the facility's policy titled, Restorative Nursing, revised July 2017, showed:- Residents will receive restorative nursing care as needed to help promote optimal safety and independence;- Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care;- Restorative goals may include, but are not limited to supporting and assisting the residents in:a) Adjusting or adapting to changing abilities;b) Developing, maintaining or strengthening his/her physiological and psychological resources;c) Maintaining his/her dignity, independence and self-esteem; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and consistently implement interventions, including adequate supervision consistent with resident needs, goals, and current professional standards of practice, in order to eliminate or reduce the risk of falls and accidents, failed to document an assessment after a fall, to notify the provider and the on-call nurse after a fall, and to update the care plan with new interventions to prevent additional falls for one resident (Resident #49) out of two sampled residents. The facility census was 47. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of five percent (%) or less. There were four errors out of 27 opportunities for errors, resulting in an error rate of 14.81%. This affected three residents (Residents #9, #30, and #36) out of five sampled residents. The facility census was 47. Review of the facility's policy titled, Administering Medications, revised April 2019, showed:- Medications are administered in a safe and timely manner and as prescribed;- Medications are administered in accordance with prescriber orders, including any required time frame. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents (Resident #30 and #36) were free from significant medication errors when staff did not administer medications as ordered by the physician and did not document the correct blood sugar reading. The facility census was 47. Review of the facility's policy titled, Administering Medications, revised April 2019, showed:- Medications are administered in a safe and timely manner and as prescribed;- Medications are administered in accordance with prescriber orders, including any required time frame. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three residents (Residents #9, #13, and #15) out of five sampled residents received the influenza (a highly contagious respiratory illness) immunization. The facility census was 47. Review of the facility's policy titled, Influenza, Prevention and Control of Seasonal, dated August 2014, showed:- The Infection Preventionist (IP) will promote and administer the seasonal influenza vaccine;- Unless contraindicated, all residents and staff will be offered the vaccine. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #1) was free from physical abuse on 07/23/25 when, as staff escorted the residents outside to smoke, Resident #2 made physical contact pushing Resident #1 down to the floor. Resident #1 was sent to the emergency room and diagnosed with a fractured hip that required surgical repair. The facility census was 60. The Administrator was notified on 07/31/25 of the Past Non-Compliance Immediate Jeopardy (IJ) which occurred on 07/23/25. Upon notification, the facility administration immediately started an investigation, notified the police department and Department of Health and Senior Services of the incident, and in-serviced all staff on the facility's policy and procedures for abuse and neglect. The IJ was corrected on 07/24/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 54. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed: - Residents are provided with a safe, clean, comfortable, homelike environment and encouraged to use their personal belongings to the extent possible; - The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting such as a clean, sanitary and orderly environment. Observations on 03/04/25 at 10:21 A.M., and 03/05/25 at 8:15 A.M., of room [ROOM NUMBER] showed: - A buildup of dust and dirt on the air filter inside the air conditioner unit; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure to complete Criminal Background Checks (CBC) for one employee (Employee I) prior to hire and to check the Employee Disqualification List (EDL - a listing of individuals who have been determined to have abused or neglected, misappropriated funds or property from a resident) periodically for six employees (Employees G, I, J, K, L, and M) out of ten sampled employees. The facility census was 54. Review of the facility's policy titled, Employee Disqualification List (EDL), dated February 2022, showed: - At the time of consideration of employment, the designated employee shall access the EDL website and check the EDL; [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit quarterly Minimum Data Set (MDS) assessments, a federally mandated assessment instrument completed by the facility, in a timely manner and in accordance with the guidelines for two residents (Residents #37 and #40) out of 14 sampled residents and two residents (Residents #38 and #42) outside the sample. The facility's census was 54. Review of the facility's policy titled, Resident Assessments, dated October 2023 showed: - A comprehensive assessment of each resident is completed at intervals designated by Omnibus Budget Reconciliation Act (OBRA) regulations and Protective Payment System (PPS) requirements. Data from the MDS is submitted to the Internet Quality Improvement Evaluation System (iQIES) as required. [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit a Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff) in a timely manner and in accordance with guidelines for two residents (Residents #17 and #41) out of 14 sampled residents. The facility's census was 54. Review of the facility's policy titled, MDS Completion and Submission Timeframes, dated October 2023, showed: - Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes; - Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument (RAI) Manual; - Submission of MDS records to the to the Internet Quality Improvement Evaluation System (iQIES) is electronic. [...]

Inspectors wroteBased on interview and record review, the facility failed to include an admitting diagnosis of post traumatic stress disorder (PTSD - psychological distress following a traumatic event) with specific interventions on the baseline care plan upon admission for one resident (Resident #158) out of two sampled residents. The facility census was 54. Review of the facility's policy titled, Care Plans - Baseline, revised March 2022, showed: - A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission; - The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meets professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain and/or follow physician's orders for three residents (Residents #15, #37 and #158) out of five sampled residents and one resident (Resident #2) outside the sample. The facility census was 54. Review of the facility's policy titled, Medication and Treatment Orders, dated July 2016, showed: - Orders for medication and treatments will be consistent with principles of safe and effective order writing; - Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; - Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement, monitor and modify interventions to maintain acceptable parameters of nutritional status for two residents (Residents #19 and #40) out of four sampled residents. The facility census was 54. Review of the facility's policy titled, Weight Assessment and Intervention, dated March 2022 showed: - Resident weights are monitored for undesirable or unintended weight loss or gain; - Residents are weighed upon admission and at intervals established by the interdisciplinary team; - Any weight change of 5% or more since the last weigh assessment is retaken the next day for confirmation; - Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at each shift change for three out of three medication carts. This practice had the potential to affect all residents. The facility census was 54. The facility did not provide a policy on narcotic reconciliation documentation. 1. Review of the 100 Hall Medication Cart Narcotic Count Log for Controlled Substances showed: - For 6 A.M.-6 P.M. shift on 02/03/25-02/24/25, the staff missed 13 out of 44 opportunities to reconcile the narcotic medications; - For 6 A.M.-6 P.M. shift on 02/25/25-03/07/25, the staff missed 6 out of 21 opportunities to reconcile the narcotic medications. 2. Review of the 200 Hall Medication Cart Narcotic Count Log for Controlled Substances showed: - For 6 P.M.-6 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an appropriate diagnosis for the use of a psychotropic (medications that affect a person's mental status) medication for three residents (Residents #1, #15, and #20) out of five sampled residents. The facility census was 54. Review of the facility's policy titled, Antipsychotic (a medication that affects the brain activities associated with mental processes and behavior) Medication Use, revised July 2022, showed: - Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; - The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 54. Review of the facility's policy titled, Refrigerators and Freezers, dated November 2022, showed: - The facility will ensure safe refrigerator and freezer temperatures, and sanitation, and will observe food expiration guidelines; - Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures; - Food service supervisors or designated employees check and record refrigerator and freezer temperatures with first opening and at closing in the evening; - Use by dates are completed with expiration dates on all prepared food in refrigerators; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1) out of four sampled residents was free of misappropriation of his/her property when Housekeeper A utilized the resident's bank card for his/her own personal use. The facility census was 57. The administration was notified on 01/26/25 of the Past Non-Compliance which occurred between 01/25/25 through 01/26/25. On 01/26/25, upon notification, the facility administration started an investigation, notified the police department and the Department of Health and Senior Services of the misappropriation. The non-compliance was corrected on 01/26/25, as the facility completed disciplinary action for Housekeeper A, in-serviced all staff on the facility's policy and procedures on misappropriation and refunded Resident #1 for the amount misappropriated. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for 12 residents (Resident #9, #17, #18, #26, #27, #28, #29, #30, #31, #32, #33 and #34). The facility staff failed to obtain written authorization from the resident and/or financial guardian for money withdrawn for five residents (Resident #1, #2, #3, #6 and #7) out of a sample of seven. Facility staff also failed to provide the Social Security and/or Medicaid monthly allowance in a timely manner, which did not allow the resident/financial guardian the right to manage all of his/her financial affairs for five residents (Resident #2, #3, #4, #6 and #9) out of a sample of five. The facility census was 53. 1. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account by not reconciling each month. The facility managed funds for 34 residents. The census was 53. 1. Record review of the facility maintained bank statements for the account ending in 2107 for the months 12/2023 through 11/2024 showed no documentation of reconciliations for the following months. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a final accounting of resident fund balances within thirty days to the individual or probate jurisdiction administering the resident's estate for one of four sampled discharged residents (Resident #18) and for one of five expired residents (Resident #16). The facility census was 53. 1. Record review of the facility maintained Discharge Report dated [DATE], showed Resident #18 discharged on [DATE]. Record review of the facility maintained Trust Transaction History Report for the period [DATE] through [DATE], showed Resident #18's money was not refunded until [DATE], 70 days after the discharge date . During an interview on [DATE] at 2:44 P.M., the Regional Accountant said the money was not refunded timely due to trying to close out the books. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1) out of three sampled residents was free of misappropriation of his/her property when Certified Nurse Aide (CNA) A utilized the resident's bank card for his/her own personal use. The facility census was 55. The administration was notified on 08/27/24 of the Past Non-Compliance which occurred between 08/09/24 through 08/14/24. On 08/14/24, upon notification, the facility administration started an investigation, notified the police department and the Department of Health and Senior Services of the misappropriation. The non-compliance was corrected on 08/14/24, as the facility completed disciplinary action for CNA A, in-serviced all staff on the facility's policy and procedures on misappropriation and refunded Resident #1 for the amount misappropriated. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide resident care for activities of daily living (ADLs) when the residents did not receive a minimum of two showers per week for nine residents (Resident #6 #15, #18, #21, #27, #29, #34, #41 and #44) ) out of 15 sampled residents and two residents (Resident #43 and #46) outside of the sample. The facility's census was 57. Review of the facility policy titled, Supporting Activities of Daily Living (ADLs), revised March 2018, showed: - Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; - Appropriate care and services will be provided for residents who are unable to carry out ADLs in accordance with the plan of care including hygiene (bathing, grooming and oral care). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's dignity was maintained while performing wound care for one resident (Resident #42) out of two sampled residents. The facility census was 57. Review of the facility policy titled, Dignity, revised February 2021, showed staff are to promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Review of Resident #42's quarterly Minimum Data Set (MDS), a federal mandated assessment to be completed by the facility, dated 09/28/23, showed: - Moderately impaired cognitive skills; - Sometimes understands others; - Makes self understood; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS) a federally mandated assessment to be filled out by the facility staff, within 14 days of an admission to hospice for for one resident (Resident #37) out of three sampled residents. The facility census was 57. The facility did not provide a policy regarding Significant Change MDS assessments. Review of Resident #37's medical record showed the resident admitted to hospice on 09/15/23. Review of the resident's MDS records showed: - No significant change MDS dated on or after 0915/23; - The facility failed to complete an significant change MDS within 14 days of the resident's admission to hospice. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #37) of two sampled hospice residents had a complete hospice (palliative care for the terminally ill with a life expectancy of six months or less) coordinated plan of care. The facility census was 57. Record review of the facility's policy titled, Hospice, revised July 2017, showed: - It is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative; - Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day; - Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care, as well as the care and services provided by the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor and consistently implement interventions, including adequate supervision consistent with resident needs, goals and current professional standards of practice, in order to eliminate or reduce the risk of falls and accidents and failed to update the care plan with new interventions to prevent additional falls for one resident (Resident #34) out of two sampled residents. The facility census was 57. Review of the facility policy titled, Managing Falls and Fall Risks, revised March 2018, showed: - The staff, with input from the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement procedures to ensure medications were accurately administered, documented, disposed of and reconciled for one resident (Resident #555) outside of the 15 sampled residents. The facility census was 57. Review of the facility's policy titled, Controlled Substances, revised November 2022, showed: - Controlled substances are counted upon delivery; - If count is correct, an individual resident controlled substance record is made for each resident who will be receiving a controlled substance; - Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow up; - The system of reconciling the receipt, dispensing and disposition of controlled substances includes: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards of practice. This had the potential to affect all residents who resided in the facility. The facility's census was 57. Review of the facility's policy titled, Controlled Substances, revised November 2022, showed: - Controlled substances are separately locked in permanently affixed compartments; - All keys to controlled substance containers are on a single key ring that is different from any other keys. Observation on 11/03/23 at 7:45 A.M., of the main medication room of the unlocked medication refrigerator showed: - One bottle of liquid lorazepam (a controlled medication used to treat anxiety) 2 milligram (mg) per milliliter (ml) for Resident #37; - One bottle of liquid lorazepam 2 mg per ml for Resident #19; [...]