Cottonwood Canyon Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe use of mechanical lift equipment (Hoyer lift) for resident transfers for one resident (Resident 1). This deficient practice had the potential to affect all residents requiring mechanical lift transfers.

Inspectors wroteBased on interview and record review, the facility left Resident 1 alone with a meal tray and did not provide feeding assistance or supervision to Resident 1 who had been assessed and identified as requiring feeding assistance and supervision (according to the facility's nutritional care plan). The facility also failed to provide adequate (one on one supervision) for Resident 1 who was assessed as a high risk for a fall and did not implement appropriate fall-prevention interventions (based on assessment of Resident 1's individual needs), for one of three sampled residents (Resident 1). [...]

Inspectors wroteBased on interview and record review the facility failed to accurately code the Minimum Data Set (MDS) to reflect the resident's true injury status following a fall, for one of three sampled residents (Resident 1). As a result, this placed Resident 1 at risk for inaccurate care planning, inappropriate monitoring and follow up, and the transmission of incorrect health information to Centers for Medicare & Medicaid Services (CMS). Cross-reference F689Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of Intellectual Developmental Disability (IDD-is a condition that limits intelligence and disrupts abilities necessary for living independently). [...]

Inspectors wroteBased on interview and record review the facility failed to develop, revise and implement an individualized, person-centered care plan to address supervision, prevent falls and feeding assistance needs for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for falls, choking, serious injury and delayed emergency response due to the lack of an individualized and implemented care plan that aligned with Resident 1's needs when:1. Resident 1, who was a high fall-risk resident, was left unsupervised, despite requiring close monitoring the comprehensive care plan lacked personalization specific to Resident 1's needs that are clear, specific, and measurable interventions to ensure continuous one on one (1:1) supervision.2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure appropriate emergency respiratory interventions, including providing rescue breaths or assisted ventilation (movement of air in and out of the lungs), for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for hypoxia (low oxygen levels), and respiratory arrest. Cross-Reference F726 and F689Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of Intellectual Developmental Disability (IDD-is a condition that limits intelligence and disrupts abilities necessary for living independently). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure staff assigned to high fall-risk residents were competent, informed, and trained to meet the residents' safety and care needs, for one of three residents sampled (Resident 1) when:1. Cardiopulmonary resuscitation (CPR) rescue breaths was not provided and only oxygen via a non-rebreather mask was administered when Resident 1 was found unresponsive with irregular breathing, and oxygen saturation was not registering on pulse oximetry (device that measures blood oxygen saturation/levels) .2. Resident 1, who was a high fall-risk resident, was left unsupervised, despite requiring close monitoring.3. Staff failed to provide feeding assistance to Resident 1, even though the resident was identified as requiring feeding assistance on a feeding assist list and required assistance with meals. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain accurate, complete and reliable medical records that reflected the actual care provided during an emergency event, for one of three residents (Resident 1). This deficient practice placed (Resident 1) at risk for delayed or inappropriate medical treatment, misinformed clinical decision-making and compromised continuity of care. Cross reference F689Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of Intellectual Developmental Disability (IDD-is a condition that limits intelligence and disrupts abilities necessary for living independently). [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement an effective discharge planning process for 1 of 3 sampled residents (Resident 5), who had severe cognitive impairment due to dementia and no family or surrogate decision-maker, when the facility did not document evidence of interdisciplinary team (IDT) meetings or third-party involvement (like conservator or ombudsman) to advocate for Resident 5's needs before her discharge to an assisted living facility on 2/27/25. This failure had the potential to result in an inappropriate placement, compromising Resident 5's safety and well-being.

Inspectors wroteBased on interview and record review, the facility failed to attempt to reschedule a resident's shower schedule or find a suitable time for a shower for one of three sampled residents (Resident 4). This failure resulted in Resident 4 not showering for 11 days, which could lead to discomfort and compromised hygiene.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an effective discharge planning process to identify and address goals for three of three sampled residents (Resident 4, Resident 5, and Resident 6). This failure resulted in rushed discharges without adequate coordination of post-discharge care, placing residents at risk for rehospitalization and inadequate support. (Cross-reference: F-656, Comprehensive Care Plans)

Inspectors wroteBased on the interview and record review, the facility failed to ensure the care plan for discharge (leaving the facility) was developed for one of three sampled residents (Resident 4). This failure increased the risk for Resident 4 to have an unsafe discharge from the facility back to the community.

Inspectors wroteBased on the interview, and record review, the facility failed to ensure comprehensive resident-centered care plans were implemented for one of two sampled residents (1) when Resident 1 had no bowel movements for three days, and the physician's order was not followed. This deficient practice had the potential to affect resident's health and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure the discharge medication list order from the hospital matched the facility's admission medication list for one of two sampled residents (1) when one tablet of Sennoside (a medication used to treat constipation) was omitted from the order. As a result, Resident 1 did not receive the desired dose of medicine to be effective.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's medical record was complete for one of two sampled residents (1) when the licensed nurse (LN) had incomplete documentation after receiving an order, and the inventory sheet (record of resident's belongings) was not signed. As a result, the facility could not verify a physician's order and Resident 1's inventory sheet when discharged was not completed. Findings Resident 1 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm (abnormal tissue growth) of ill-defined sites within the digestive (a group of organs that work together to digest and absorb nutrients from the food that was eaten) system, per the admission Record. A review of Resident 1's medical record was conducted. Per the Progress Notes, dated; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to offer written and follow-up initiation of the advance directives for seven of 20 sampled residents (Residents 10, 29, 77, 36, 237, 61 and 62). This failure resulted in staff not knowing residents' directives regarding care and the residents' legal health care agent.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure opened dressings were labeled with an open date, and expired food was removed from the walk-in refrigerator in the kitchen. These failures placed residents at risk of acquiring foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four of 20 residents reviewed had accurate and complete medical records when: 1. Resident 66's treatment record was incomplete, 2. Resident 23's post dialysis note was incomplete and did not indicate reassessment after dialysis site bleeding, 3. Resident' 36 and Resident 63's Diabetic Administration Record was incomplete. This failure did not provide an accurate representation of the care provided to the residents and had the potential for residents to not receive the appropriate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed when an expired disinfectant (kills or inactivates germs) wipes were removed from the cart, and a resident with a wound infection was not placed on Enhanced Barrier Precaution (EBP-infection control measure to prevent spread of infection) timely. These deficient practices could potentially spread infectious diseases in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure call lights were answered in a timely manner for a confidential group. This failure resulted in resident's suffering a lack of dignity when the confidential group voiced anger and frustration over call light incidences with the facility staff. The facility census was 86.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident had an authorized responsible party to sign the informed consent for the use of the psychotropic medication (medications that affect brain activities associated with mental processes and behaviors) for one of five sampled residents reviewed for unnecessary medications (Resident 10). This failure may result in a conflict that impacts the decision-making process for Resident 10.

Inspectors wroteBased on interview and record review, the facility failed to ensure an advanced beneficiary notice (ABN- waiver of liability) was offered in one of six residents (Resident 39) reviewed for discharge . This failure had the potential for Resident 39 to not have options with regards to Resident 39's discharge placement or location and care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure comprehensive resident-centered care plans were developed and implemented for two of 20 sampled residents (Resident 29 and 62) when: 1. Resident 29 was not assisted in repositioning while in bed, and nail care was not performed. 2. Resident 62's pressure ulcer was not care planned. These failures had the potential to affect resident's care needs.

Inspectors wrote2. A review of the facility's admission Record indicated Resident 286 was admitted to the facility on [DATE] with diagnoses that included morbid obesity and malignant neoplasm (cancer) of the body of the stomach. An interview on 12/9/24 at 9:35 A.M., with Resident 286 was conducted. Resident 286 stated she arrived Thursday night 12/2/24. Resident 286 stated no one has done the treatment to her jejunostomy tube site (JT- a tube inserted into the small intestine to help with nutrition and hydration) and other LNs administered her medications by mouth instead of through her JT. A review of Resident 286 Minimum data set (MDS- a federally mandated assessment tool) dated 12/12/24 indicated a BIMS (brief interview for mental status) score of 15 which meant Resident 286's cognition was intact. An interview on 12/10/24 2:45 P.M., with LN 31 was conducted. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to arrange an appointment for audiology (measure and evaluate hearing) for one of one residents reviewed for Vision and Hearing (Resident 59). This failure resulted in Resident 59 not having access to hearing aids to maintain his hearing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure professional standards of practice when: 1. Physician's order for oxygen was not followed (Resident 16), 2. There was no order for oxygen (Resident 237). As a result, Resident 16 was provided with more oxygen than what was ordered. In addition this failure had the potential to affect Resident 237's respiratory status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two residents reviewed (Resident 9), received Trauma Informed Care (TIC- an intervention and organizational approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health). This failure resulted in the facility's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past torture experience).

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR- a thorough evaluation of the resident's current medications) was completed monthly for one of five sampled residents selected for an unnecessary medication review (Resident 10). As a result, there was a potential for Resident 10 to receive unnecessary medications and medication irregularities to go unattended.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five selected sampled residents (Resident 10) reviewed for psychotropic (a drug or substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) had specific behavior monitoring in place for the use of antipsychotic ( a class of drugs that treat symptoms of mental disorder by altering brain function). This failure had the potential to result in unnecessary use of psychotropic medication.

Inspectors wroteBased on interview and record review, the facility failed to maintain staffing based on payroll data on quarterly schedule to Centers for Medicare & Medicaid Services (CMS-government agency overseeing nursing health facilities) for one of four fiscal quarters (4th quarter of 2024 [07/01/24 to 09/30/24]). This failure in excessively low weekend staffing resulted in not meeting staffing requirements by CMS.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered comprehensive care plan related to refusal of care, for one of two residents (Resident 1) who repeatedly refused to ingest the prescribed medications, reviewed for Quality of Care. The failure had the potential for medical complications and a decline in health status.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure effective pain management services were provided to residents when two of four residents (1, 2) complained of inadequately controlled pain. This failure resulted in psychological harm when the residents experienced unrelieved pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:(1) document a change in the resident's condition's or status for one of three sampled residents (Resident 1) before starting Lorazepam (a medication that affects mood, emotions, and behaviors), and (2) ensure the licensed nurse (LN) correctly transcribed the physician's order for one of three sampled residents (Resident 1). As a result, Resident 1 had the potential to receive unnecessary medication without proper monitoring of the behavior.

Inspectors wroteBased on the interview and record review, the facility failed to ensure the MDS (Minimum Data Set- a comprehensive resident assessment) was accurate for 1 of 2 sampled residents (1) with an indwelling catheter (a tube inserted into the bladder to drain urine out of the body). As a result, Resident 1 did not consistently receive appropriate treatment and service.

Inspectors wroteBased on observation, interview and record review, the facility did not assess one resident, (Resident 1), for PTSD (Post Traumatic Stress Disorder, a disorder that develops when a person has experienced or witnessed a terrifying or dangerous event. The disorder can cause intense distress at real or symbolic reminders of the trauma) when, Resident 1 was admitted with a known diagnosis of PTSD. This failure had the potential to expose Resident 1 to trauma triggers while in the care of the Facility.

Inspectors wroteBased on observation,interview and record review, the facility did not provide for the Resident's (2) Rights related to transportation services. This failure caused the Resident to miss a medical appointment.

Inspectors wroteBased on observation, interview and record review the facility failed to develop comprehensive care plans for two Residents (1) and (2). This failure had the potential for Residents 1 and 2 to not receive needed care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen staff competently carried out the functions of the food and nutrition services department when: 1. A [NAME] (CK 1) did not monitor the dry storage room by correctly checking the quality of the food supply and the temperature, and 2. CK 1 did not prepare the tuna salad correctly using the cool down process for ambient temperature foods. These failures had the potential for food contamination, resulting in food borne illnesses for all residents who consume food from the kitchen. The census was 66.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored in a safe and sanitary manner, according to the facility policy and standards of practice within the Food and Nutrition Services department when: 1. The dry storage room was: a) not pest-free, b) contained a large bin of white onions some with black mold spots, c) at a temperature of 82 degrees Fahrenheit (F); 2. The tuna salad and egg salad was not prepared in a food safe manner when the kitchen staff did not use the cool down process for ambient temperature foods; 3. The dishes were stored wet. These failures had the potential to put the residents at risk for foodborne illnesses. Cross reference, F802 and F925.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment was free of pests. This failure had the potential for the cross-contamination of foods stored in the kitchen, foods being prepared during tray line, and during meal times, resulting in food-borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four of four residents reviewed for Activities of daily living (ADL, which includes good nutrition, grooming, personal and oral hygiene) had adequate personal hygiene care (Residents 11, 15, 48, 58). This failure had the potential to cause infection, and impact quality of life and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to perform reference checks for one of one CNAs (CNA 11) reviewed for a complaint. This failure had the potential to place residents at risk for abuse or neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician's orders when: 1. Restorative Nursing Assistant services (RNA, exercises and stretching to help maintain function of the muscles of the limbs) were not provided for four of four residents reviewed for limited range of motion (Residents 11, 15, 48, 58). 2. Medication administration was completed via a gastrointestinal tube (GT, a tube inserted into the wall of the abdomen directly into the stomach, Resident 38), and 3. A controlled drug was administered to Resident 47. As a result, the residents were at risk for: 1. Muscle weakness and an inability to function independently. 2. Occlusion (blockage) of the GT which could lead to an unnecessary and invasive procedure of replacing GT. 3. Overmedication of controlled drugs, which could have resulted in respiratory failure (inability to breath).

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent a deep tissue injury (DTI, damage of the underlying soft tissue from intense and/or prolonged pressure) from developing for two of three residents reviewed for wounds (Residents 66, 56). As a result, the residents had the potential for increased pain and prolonged wound healing.

Inspectors wroteBased on interview and record review, the facility failed to complete an assessment after dialysis (a treatment to remove waste from the body) for one of one residents reviewed for dialysis (Resident 12). As a result, there was the potential for undetected, potentially life-threatening complications after dialysis.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy for two of three residents (Residents 41 & 47) reviewed for controlled drugs (drugs at high risk for abuse). As a result, the facility was at risk for controlled drug loss and theft.

Inspectors wroteBased on observation, interview and document review, the facility failed to monitor the temperatures of their medication refrigerator per the facility's policy. This failure had the potential to affect the integrity of the refrigerated medications administered to the facility's residents, putting their health at risk. On 7/14/21 at 12:02 P.M., an observation, interview, and concurrent document review were conducted with the facility's DSD. The facility's document titled Med Room Refrigerator Temp Log dated June 2021, indicated, no staff signatures or temperature readings were documented on 7/1/21 for A.M and P.M., 7/7/21 for A.M. and P.M., and 7/12/21 for P.M. The facility's DSD stated the medication refrigerator temperatures should be checked and documented per the facility's policy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two residents (32 and 36) received food that accommodated their food preferences. This failure had the potential to result in decreased food intake and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safe and sanitary handling of residents' foods brought in from the outside, as per the facility's policy, and the standards of practice. This failure had the potential to expose the residents to food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Resident medications were available for administration for two of 18 sampled residents (58, 238). As a result, there was the potential for ineffective pain management for the residents. 2. Resident medications were administered as ordered through a J-tube (jejunostomy tube is a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine) for one resident sampled for J-tube medication administration (9). As a result, there was the potential to negatively impact the resident's ability to maintain the highest level of practicable well-being. 3. The pharmacy reviewed medications for irregularities for a new resident (78). As a result, there was potential for the resident to experience harmful, medication-related side effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the staff followed infection control policy and accepted standards when staff members did not perform hand hygiene between seven unsampled residents (15, 35, 77, 109,188, 190, and 241) or sanitize resident equipment. As a result, there was the potential for the spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. Room temperatures were comfortable and safe for four of 18 residents (35, 81, 238, 239) sampled for environment. This failure caused Residents 35, 81, 238 and 239 to feel cold and uncomfortable, and had the potential to cause hypothermia. 2. The wall and ceiling in the laundry room were in good repair. This failure had the potential to contaminate the clean laundry, and to affect all residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care plans were resident-centered for 3 of 3 residents (3, 24, 74 ) sampled for care plans. 1. Resident 74's care plan did not include person-centered, non-pharmacological (non-medication) interventions when anxiety was displayed, which had the potential to result in the administration of unnecessary psychotropic medications and reduce the resident's quality of life. 2. Resident 3 and 24's care plans did not include their preferences for activities, which had the potential to affect their quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to evaluate resident's activity preferences and offer meaningful, person-centered activities that met the interest and needs for 2 of 3 residents (3, 24) sampled for activities. This failure had the potential to cause boredom, depression and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide evidence of documentation of non-pharmacological behavior interventions, prior to the administration of a psychotropic medication (a medication that affects mental processes and behavior), for 1 unsampled resident (74). This failure had the potential to result in the administration of unnecessary psychotropic medications and reduce Resident 74's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the prescribing physician documented an evaluation and rationale for a psychotropic medication (a medication that affects mental processes and behavior) for 1 unsampled resident (74). This failure had the potential to result in the administration of unnecessary psychotropic medications and reduce Resident 74's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a hospice agency's documentation of services and prospective visit calendar was present in the clinical record for two of two hospice residents (46, 58). As a result, there was the potential to put the residents at risk for delayed or uncoordinated care between the facility healthcare team and the hospice agency.