Cottonwood Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a notice of transfer to 51 long-term care residents and/or their representatives at least 30 days before transfer, when 51 residents were transferred to other facilities within 10 days of transfer notification. This failure decreased the facility's potential to provide safe and effective transition of care while maintaining the residents' highest practicable physical, mental and psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to employ a fully qualified nutrition professional who was employed full time (35 hours a week or more) to oversee the dietary department. This failure had the potential for unsafe food handling, and food borne illness in a highly susceptible population of 95 residents. FindingsDuring the initial kitchen tour on 7/6/26 at 8:49 a.m., a kitchen staff member pointed out the Dietary Services Manager (DSM) as the person in charge of the dietary department. DSM stated he had worked in the position for the past two and a half years. When asked about his qualifications for the position, DSM stated he was in school to become a Certified Dietary Manager (CDM) and his classes would start next semester. DSM clarified he worked under the guidance of a CDM who was located at a sister facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions, when:Hair/facial hair was not properly secured;Bags used for bulk food items were not food grade;The red cutting board (used for meat) was found with a deep gouge;Food service items were stored wet;Counter and cart cleaning did not include a wash and rinse step prior to sanitizing; andThe red bucket used for sanitizer was not tested correctly. These failures had the potential of leading to food poisoning for the 95 vulnerable residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the plan of care for one of 23 sampled residents (Resident 29), when a communication board/binder was not accessible for staff to communicate with Resident 29. This failure decreased the facility's potential to effectively communicate and meet Resident 29's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician order was followed for one of 23 sampled residents (Resident 29), when Resident 29's physician order for one-on-one feeding was not implemented. This failure increased Resident 29's potential for low meal consumption.

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled residents (Resident 1's) right to be free from misappropriation of property, when Certified Nursing Assistant (CNA) 1 cashed Resident 1's bank check without consent. This failure had the potential to negatively impact Resident 1's highest practicable mental and psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents' rights to personal privacy and confidentiality of his or her personal medical information, when meal tray tickets were found thrown into the general trash. This had the potential to compromise resident privacy and confidentiality for the 95 residents residing in the facility. During a concurrent observation and interview on 7/27/25, at 9:13 a.m., with the Dietary Aide (DA) in the kitchen, DA was observed throwing away residents' meal tickets into a garbage can. DA stated meal tickets that are left on meal trays are thrown into the kitchen garbage can and the garbage can is then later emptied into the outside garbage bin. DA confirmed the meal tickets contained resident's names and diet information and that anyone can access them after the meal tickets are dumped into the outside garbage bins. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored in accordance with the facility's policies and procedures (P&P), and accepted professional principles for a census of 95 when:1. A total of 5 loose pills were found in medication cart 4;2. An opened Polymyxin B-tmp eye drop (an eye drop used to treat bacterial eye infections), an opened Incruse Ellipta inhaler (a medication used to treat airflow obstruction in adults), and an opened Symbicort inhaler (a medication used to treat breathing difficulty) had no opened date label; and,3. A used Latanoprost eye drop (a prescription medication used to manage elevated eye pressure) was not discarded after 28 days. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication administration practices when the facility's medication error rate was more than 5% (percentage- number or ratio that expressed as a fraction of 100) for a resident census of 95. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of five errors out of 34 opportunities which resulted in a facility wide medication error rate of 14.71% in four out of 11 residents (Resident 34, 40, 32, and 27) observed for medication administration. These failures had the potential for unsafe and ineffective medication use of Resident 34, 40, 32, and 27 and had the potential to negatively affect the residents' medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe, sanitary care for a census of 95 when:Resident 13's indwelling catheter (tube placed into the bladder to drain urine) drainage bag was uncovered and on the floor;Resident 19's nebulizer tubing was not changed every seven days; and Facility staff did not wear the required PPE when entering an isolation room. These failures increased the risk of infection. 1. Resident 13 was admitted to the facility early 2025 with diagnosis which included sepsis (life threatening complication of an infection), urinary calculus (mineral deposits that form in the urinary tract), and kidney infections. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two out of 25 sampled residents (Resident 110 and Resident 92) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 110 and Resident 92 pain medication orders were not consistently followed. This failure had the potential for Resident 110 and Resident 92 to develop medication dependence (the inability of the individual to function normally in the absence of the drug), overdose, not achieve pain relief, and not attain their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe and effective pharmaceutical services for two out of 25 sampled residents (Resident 110 and Resident 92) when Resident 110 and Resident 92's controlled drug (drug with potential for abuse) use and removal signed out from the Controlled Drug Record (CDR- a paper log of controlled drug removal for administration to resident) was not documented in their Medication Administration Record (MAR-a legal document that list administered drugs). This failed practice may contribute to unsafe medication use and handling, and risk of controlled drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 25 sampled residents (Resident 32 and Resident 27) was free from significant medication error when Resident 32 and Resident 27 did not receive their prescribed insulin (medication used to manage blood sugar level) in accordance with the physician's order and standards of practice. This failure has the potential to result in Resident 32 and Resident 27 experiencing hypoglycemia (too low blood sugar level) and other unnecessary insulin side effects which could negatively affect the resident's health.

Inspectors wroteBased on interview and record review, the facility failed to ensure services were provided to meet professional standards of quality for one of eight sampled residents (Resident 1) when Resident 1's physician was not informed of a medication that was not available and not administered as prescribed. This failure had the potential to put Resident 1's health and safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for 1 of 8 sampled residents (Resident 3) when Resident 3's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was observed on the side of the bed, uncovered and undated when not in use. This failure increased the risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal the need for help) was accessible for 1 of 8 sampled residents (Resident 2) when Resident 2 was not physically able to use the call light provided when it was out of reach. This failure had the potential to result in unmet resident needs and delayed staff response.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse for one of three sampled residents (Resident 1) when Resident 2 hit the leg and grabbed the arm of Resident 1. This failure resulted in an injury to Resident 1 ' s left arm.

Inspectors wroteBased on interviews, clinical record review, and facility documents review, the facility failed to ensure one of three Residents (Resident 1) was treated with dignity and respect when Certified Nursing Assistant (CNA) 1 raised her voice and cussed at Resident 1. This failure resulted in Resident 1 feeling scared.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored correctly for census of 87 when: 1. Two bottles of sodium chloride (a solution used to dilute medications) were found expired in the automatic dispensing system inside the medication room of station 1 and 2; and, 2. Multiple medications were found at the bottom of medication carts behind the medication drawers in medication carts 3 and 5. These failures had the potential for medication misuse, ineffectiveness, diversion, and missed dosages.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure the competency of food and nutrition services for a census of 87 when: 1. Dietary Staff 2 (DS 2) did not know the chlorine sanitizing concentration when performing the three compartments of manual dish washing; 2. Dietary [NAME] 1 (DC 1) did not follow standardized recipes when cooking green beans; and, 3. DC 2 did not follow the recipes when making pureed bread. These failures had the potential to cause contamination of food resulting in food borne illness and provide food for residents which did not meet the nutrients according to the planned recipes resulting related medical issues.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner for a census of 87 when: 1. Seven snack cookie bags and seasoning bottles were stored past their expiration date and several food items were opened and not dated with their open date in the dry storage; and, 2. Staff did not check and document the ammonia log when performing test strips for one shift on 8/11/24. These failures had the potential to result in foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee met at least quarterly with the required members for a census of 87, when the QAA committee did not meet in the first quarter of 2024, and the Medical Director (MD) and Director of Nursing (DON) did not attend two meetings. This failure had the potential to negatively impact the quality of resident care.

Inspectors wrote2. A review of admission Record indicated Resident 79 was admitted in May 2024 with diagnoses including End Stage Renal Disease (Kidneys stopped working) and Dependence on Hemodialysis (life sustained through hemodialysis). During an observation on 8/13/24 at 09:44 a.m. with LN 6, Resident 79 was observed with a hemodialysis catheter at right chest with two lumens (channels) and covered with clean dressing. During a review of Resident 79's Physician's Orders, dated 5/21/2024 indicated, an order of hemodialysis three times a week on Tuesday, Thursday, and Saturday, and orders changed on 6/6/2024 to hemodialysis on Monday, Wednesday, and Friday. During a review of Resident 79's MDS, dated [DATE], the MDS indicated, Resident 79 was not receiving hemodialysis. During a concurrent interview and record review on 8/14/2024 at 2:45 p.m. with MDSC, Resident 79's MDS, dated [DATE], was reviewed. [...]

Inspectors wroteAccording to an admission Record for Resident 82 he was admitted to the facility in late June 2024 with diagnoses including dementia (loss of cognitive functioning to an extent that it interferes with a person's daily life and activities) with agitation. During observation rounds on 8/13/24 at 9:28 a.m., Resident 82 was observed inside his room able to get up on his own, ambulate without using equipment and was wearing a wander guard bracelet to his right ankle. A review of Resident 82's Order Summary Report, dated 6/21/24, indicated an order for a wander guard to be worn due to elopement risk. Review of Resident 82's Care Plans revealed there was no care plan in place that addressed Resident 82's use of a wander guard. In a concurrent interview and record review on 8/14/24 at 1:47 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise care plan interventions in a timely manner following a change in condition for one of 19 sampled residents (Resident 14), when Resident 14 developed moisture associated skin damage (MASD) and a right hip pressure ulcer (skin and tissue injury). This failure decreased the facility's potential to provide Resident 14 with a person-centered care plan and evaluate its effectiveness.

Inspectors wroteBased on interview and record review, the facility failed to identify and assess the skin condition for one of 19 sampled residents (Resident 14), when the licensed nurses did not assess or inaccurately assessed Resident 14's skin condition before she developed a right hip pressure ulcer (skin and tissue injury). This failure decreased the facility's potential to prevent Resident 14's development of pressure ulcer.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care services according to professional standards of quality for one of 19 sampled residents (Resident 244) when Resident 244's administered oxygen was not consistent with physician's order. This failure decreased the facility's potential to safely follow the physician's order when providing respiratory services and increased the resident's risk of developing lung problems.

Inspectors wroteBased on interview and record review, the facility failed to complete the annual performance evaluations for three of seven sampled certified nursing assistants (CNAs; CNA 1, CNA 2, and CNA 3). This failure increased the residents' potential to receive poor quality of care from CNAs.

Inspectors wroteBased on interview and record review, the facility failed to act on the Consultant Pharmacist's Medication Regimen Review (MRR) recommendation for one of 19 sampled residents (Resident 24) when the physician did not address Resident 24's MRR recommendation related to the use of risperidone tablet (an antipsychotic medication, that affects brain activities associated with mental processes and behavior). This failure had the potential to increase Resident 24's risk for the continued use of an antipsychotic medication without adequate indication that could cause adverse consequences.

Inspectors wroteBased on interview, and record review the facility failed to ensure one of 19 sampled residents (Resident 24) was free from unnecessary psychotropic medication (drugs that affects brain activities associated with mental processes and behavior) when Resident 24 was ordered an anti-psychotic medication without an adequate indication. This failure placed the resident at risk for unnecessary psychotropic medication use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices for a census of 87 when Dietary Staff 1 (DS 1) did not change gloves and perform hand hygiene after cleaning and disinfecting the kitchen cart and touched clean kitchen items. This failure had the potential to spread infection in the facility.

Inspectors wroteBased on interviews, clinical record review, and facility documents review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with dignity and respect when Certified Nursing Assistant (CNA) 1 refused to assist Resident 1 with cleaning, pulling up his brief, and sat him in his wheelchair with his pants down while still soiled with feces. This failure resulted in Resident 1 to feel sad and left soiled.