Cottonwood Nursing & Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program to the maximum extent practicable to avoid duplicative testing and effort, which included submitting a complete and accurate request for nursing facility specialized services (NFSS) which included a customized manual wheelchair. The facility failed to submit a complete and accurate request for nursing facility specialized services form within 20 business days from the Interdisciplinary Team Meeting held on 04/22/26 for Resident #1. On 07/08/26, a meeting was held when it was discovered the original NFSS form had not been submitted and was submitted late on 07/27/26. This failure could place residents at risk of not receiving specialized services that would enhance their highest level of functioning.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices on each resident that were complete and accurately documented for 1 of 4 residents (Resident #2) reviewed for accuracy of record. The facility failed to ensure LVN A documented Resident #2's medication administration of her PRN pain medication, Fioricet (barbiturate combination analgesic) when she documented on the Individual Control Drug Record paperwork but failed to document them on Resident #2's e[DATE] times from 3/30/26 to 6/29/26. This failure could place residents at risk for incorrect medication administrations due to misinformation from incomplete and inaccurate medical records. Record review of Resident #2's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two residents (Resident #1 and Resident #2) reviewed for abuse and neglect. The facility failed to ensure Resident #2 was free from abuse on 6/21/26, when Resident #1 approached Resident #2 in the smoking area and hit Resident 2 in the face. No injuries were observed. This failure could place residents at risk of abuse and physical harm.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for accident prevention for 1 of 4 resident halls (Hall 3) observed for safety hazards. The Maintenance Director failed to ensure his toolbox was closed and secure from residents gaining access to it on Hall 3. This failure could result in the residents accessing the toolbox and using tools to potentially harm themselves or others.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' food and drink was palatable, attractive, and at a safe and appetizing temperature for 37 of 39 residents on regular, mechanical, or pureed diets. The Dietary Manager failed to ensure the residents' meals were at a safe and appetizing temperature. This failure could result in the residents consuming food at unsafe temperatures and experiencing unhealthy weight loss.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of four residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1's nasal canula was properly stored in a bag when not in use on 01/06/26. This failure could place the resident at risk for respiratory infection and not having his respiratory needs met.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen for food and nutrition services.1. The facility failed to seal, label and date refrigerator and freezer food items.2. Dietary staff failed to dispose of expired foods items in the pantry and refrigerator. These deficient practices could place residents at risk for cross-contamination and foodborne illness.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #5, Resident #9, and Resident #40) of twenty-one residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #5, Resident #9, and Resident #40's rooms were in a position that was accessible to the resident on 08/12/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team for six (Residents #2 #9, #10, #12, #29, and #44) of eight residents reviewed for care plan revision. The facility failed to complete a quarterly care plan for Residents #2, #9, #10, 312, #29, and #44. This failure could place the residents at risk of care and needs not being met.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one (Resident #44) of four residents reviewed for quality of care. The facility failed to ensure that LVN A did not use one gauze to clean Resident #44's scattered wounds, non-pressure related wound to her left posterior (towards the back) thigh on 08/12/2025. This failure could place the residents with scattered wounds at risk for worsening of existing wounds and infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for one of three residents (Resident #40) reviewed for feeding tube (a way of providing nutrition directly to the stomach). The facility failed to ensure Resident #44 had an order to flush the g-tube before and after medication administration on 08/13/2025. This failure could place residents at risk for infection and development of obstruction of the g-tube.

Inspectors wroteBased on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for four of sixteen residents (Resident #2, #11, #30, and #42) reviewed for medication storage. 1. The facility failed to ensure Resident #2's zinc oxide (medicated cream used to prevent skin irritation) was not left inside the resident's room on 08/12/2025. 2. The facility failed to ensure Resident #11's zinc oxide was not left inside the resident's room on 08/12/2025. 3. The facility failed to ensure Resident #42's zinc oxide was not left inside the resident's room on 08/12/2025. 4. [...]

Inspectors wroteBased observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of fifteen residents (Resident #6 and Resident #44) reviewed for infection control. 1. The facility failed to ensure CNA D and CNA E changed their gloves during Resident #6's incontinent care on 08/13/2025. 2. The facility failed to ensure LVN A did not put Resident #44's catheter bag on top of the bed's linen. 3. The facility failed to ensure LVN performed hand hygiene and wore a gown while turning Resident #44 on 08/12/2025. 4. The facility failed the ensure CNA E did not touch the new linens after touching the catheter when changing Resident #44's beddings on 08/12/2025. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy and confidentiality of his or her personal and medical records for two (Resident #40 and Resident #44) of eight residents reviewed for privacy and confidentiality. 1. The facility failed to ensure the ADON closed, locked, or minimized her laptop's monitor while preparing Resident #40's medication via g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach) on 08/13/2025. 2. The facility failed to ensure LVN A closed the door while performing ADL on Resident #44 on 08/12/2025. These failures could place the residents at risk of not having their personal privacy maintained during ADLs and their medical information exposed to unauthorized individuals.

Inspectors wroteBased observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection and to restore continence to the extent possible for one of (Resident #44) two residents reviewed for catheter care. The facility failed to ensure that LVN A placed Resident #44's catheter bag (collects urine from the urinary bladder) below the bladder on 08/12/2025. This failure could place residents with catheter at risk for urinary tract infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of twelve residents (Resident #29 and Resident #31) reviewed for respiratory care.1. The facility failed to ensure Resident #29 's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was stored properly when not in use on 08/13/2025. 2. The facility failed to ensure there was a sign outside Resident #29's room that reflected oxygen was in use. 3. The facility failed to ensure Resident #31's breathing mask was stored properly when not in use on 08/12/2025. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals that met the needs of each resident for one of eight residents (Resident #30) reviewed for pharmaceutical services. The facility failed to ensure vials of solutions used for breathing treatment were not left inside Resident #30's room for the resident to administer by himself on 08/12/2025. This failure could place residents at risk of not receiving medications as ordered by the physician, potential overdose, and adverse effects.

Inspectors wroteBased observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of ten residents (Resident #1) reviewed for Infection Control. The facility failed to ensure CNA A and CNA B performed hand hygiene and changed their gloves while providing incontinent care to Resident #1 on 12/05/2024. This failure could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for two of (Resident #16 and Resident #20) eight residents reviewed for Care Plans. 1. The facility failed to ensure Resident #16 was care planned for smoking. 2. The facility failed to ensure Resident #20 was care planned for hospice and enteral Feeding. These failures could place the residents at risk of not receiving necessary care and services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that Residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Residents #26, #30, and Resident #189) of eight residents reviewed for Respiratory Care. 1. The facility failed to ensure an Oxygen In Use sign was placed outside of Resident #26's room. 2. The facility failed to ensure Resident #189's mask for CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) was properly stored. 3. The facility failed to ensure Resident #30's oxygen mask was properly stored. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. The facility failed to ensure food in the facility's refrigerator, was labeled and dated according to guidelines. The facility failed to ensure the ice machine and ice scoop holder were thoroughly cleaned. The facility failed to ensure food in the facility's freezer, was labeled and dated according to guidelines. The facility filed to ensure kitchen equipment was thoroughly cleaned. These failures could place residents at risk for cross contamination and other air-borne illnesses.

Inspectors wroteBased observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (Resident #23, Resident #19, Resident #9, Resident #28, Resident #1, and Resident #26) of twelve residents observed for infection control. 1. The facility failed to ensure that CNA A changed his gloves and perform hand hygiene while providing incontinent care to Resident #23. 2. The facility failed to ensure that LVN B sanitized the blood pressure cuff between Resident #19, Resident #9, Resident #28, and Resident #26. These failures could place the residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #23 and Resident #26) of nineteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #23 and Resident #26's rooms were in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents ' choices for 1 (Resident #10) of 6 resident reviewed. for quality of care. The facility failed to obtain physician's orders and assess Resident #10 for a scoop mattress prior to installing the scoop mattress. This failure could prevent the resident to from being free of any physical harm .

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral (intake of food through a tube in the gastrointestinal tract) feeding for one (Resident #20) three residents reviewed for gastrostomy tube management. The facility failed to ensure that LVN B checked Resident #20's G-tube (Gastrostomy tube: A tube directly inserted through the skin to the stomach to deliver nutrition) placement prior to medication administration. The facility failed to ensure that LVN B checked Resident #20's residual (amount of liquid remaining in the stomach) before administering medications via gastrostomy tube. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for food storage. The facility failed to ensure expired foods were discarded upon expiration date. This failure could place residents at risk for food-borne illnesses.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. for 1 of 12 residents (Resident #190) reviewed for Baseline Care Plans. The facility failed to ensure Resident #190 had a Baseline Case plan developed within 48 hours of a resident's admission. This failure placed resident at risk of not receiving immediate care if assistance was needed. Findings Included: Record review of Resident #190's Face Sheet, dated 05/17/23, revealed he was a 81 -year-old male admitted on [DATE]. Relevant diagnoses included chronic obstructive pulmonary disease (lung disease), chronic kidney disease (kidney failure), chronic congestive heart failure (heart failure), dementia, and repeated falls. [...]

Inspectors wroteBased on observation, interview and record, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Resident #32) of five residents reviewed for care plans. The facility failed to ensure for accuracy and effectively implement Resident #32's comprehensive care plan. This failure can result in the facility not meeting Resident #32's specific care needs related to her anti-hypertensive medication regimen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 4 residents reviewed for ADLs (Resident #32). The facility did not shower Resident #32 regularly. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, feelings of poor self-esteem, lack of dignity and health.

Inspectors wroteBased on observation, interview and record, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Resident #32) of five residents reviewed for quality of care. The facility failed to sufficiently monitor Resident #32's blood pressure while she was taking anti-hypertensive medication Amlodipine and failed to implement Resident #32's comprehensive care plan intervention to take her blood pressures daily. This failure could place residents at risk for adverse effects of an anti-hypertensive medicine regimen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the activity program was directed by a qualified professional who was licensed, registered, had qualified work experience or had completed a training course approved by the State for one (AD) of one Activity Director. The facility failed to have a qualified Activity Director. The previous Activity Director left employment five days prior and the facility did not fill the position, only having facility staff try to fill in who were not qualified or had the experience. This failure placed all residents at risk of receiving inappropriate activities.