Haven of Cottonwood

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure one of ten sampled residents (Resident #25) received prescribed anticoagulant medication, apixaban, in accordance with professional standards of practice when the medication was documented as self-administered without the required assessment, order, or care plan. The census was 72. The deficient practice could result in complications related to not receiving the prescribed medication.

Inspectors wroteBased on interviews, review of clinical record, and review of facility policy and procedures, the facility failed to ensure wounds were adequately assessed and monitored for one resident. The deficient practice could result in the clinical team not being fully aware of a resident's wound status and could lead to a delay of care for a worsening or non-healing wound.

Inspectors wroteBased on clinical record review, facility documentation, resident and staff interviews, the facility failed to ensure that one resident (#11) was discharged in a manner that prevented accident hazards. The deficient practice resulted in a resident being inadvertently discharged with a Peripherally Inserted Central Catheter (PICC) line in place, which could pose a risk of infection or potential misuse of the PICC line.

Inspectors wroteBased on observations, interviews, facility documentation and policy, the facility failed to ensure a clean, sanitary, and safe environment in the residents' shower rooms, and in shared resident bathroom on the 200-Hall. The deficient practice could result in the spread of infection and the failure to achieve a home-like environment.

Inspectors wroteBased on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure an allegation of abuse was reported timely to required entities for one resident (#326). The deficient practice could lead to ongoing abuse leading to harm of a resident.

Inspectors wroteBased on clinical records, review of facility documentation, review of the State Agency (SA) database, staff interviews and review of policy and procedure facility failed to ensure two allegations of abuse (resident #171& #326) and an allegation of neglect (resident #26) were fully investigated. The deficient practice could result in allegations of abuse and neglect not being investigated and abuse/neglect occurring in the facility.

Inspectors wroteBased on documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to assess and monitor the activities for one resident (#24).

Inspectors wroteBased on clinical record reviews, staff interviews, facility documentation, policy and procedures, the facility failed to ensure adequate supervision to prevent elopement for one resident (#34); and, failed to ensure one resident (#324) was free from preventable accidents of repeated falls. The deficient practice could result in avoidable accidents and/or decline in fuction.

Inspectors wroteBased on staff interviews and review of facility documentation and policy, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. The census was 67 and the sample was 20. The deficient practice could result in residents not receiving advanced care activities to meet their needs.

Inspectors wroteBased on observations, interviews, facility documentation and policy, the facility failed to ensure safeguards and systems were in place to ensure accurate reconciliation and accounting for all controlled substances. The deficient practice could result in inventory loss, and potential diversion.

Inspectors wroteBased on observations, staff interviews, and a review of facility documentation and policies, it was found that the facility failed to incorporate food safety, storage and hygiene. Findings Include: -Regarding food storage and expired food items: A kitchen observation was conducted with the morning cook (staff #20) on April 18, 2025 at 9:53 AM and revealed the following: - food items found in the refrigerator were beyond their use by date and food items were not sealed properly. -Within the large, three-door refrigerator,cooked bacon was discovered wrapped in tinfoil and lacked any date labeling. - A full one-pound plastic container of strawberries contained two strawberries exhibiting approximately one-inch diameter white colored substance. - A one-gallon plastic bag of lettuce was observed to be brown and wilted, and the bag was undated. [...]

Inspectors wroteThe facility failed to ensure that staff followed appropriate infection control practices. The deficient practice could result in a spread of preventable illness to residents and staff.

Inspectors wroteBased on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure one resident (#326) was treated with respect and dignity. The deficient practice could lead to psychosocial harm of a resident.

Inspectors wroteBased on clinical record review, interviews, facility documentation and policy, the facility failed to ensure that one resident's (#47) consent was given prior to the administration of a psychotropic medication. The deficient practice could result in the resident not being informed of the risk and benefits of proposed care and not being given the opportunity to choose the care option of care he or she prefers.

Inspectors wroteBased on clinical record, staff interviews, review of facility documentation, policy and procedures and the State Agency (SA) database the facility failed to implement their policy regarding conducting thorough investigation of abuse/neglect allegation and protecting residents from further abuse for two residents (#26 and #171). The deficient practice could result in abuse/neglect continuing and not being prevented.

Inspectors wroteBased on closed record review, staff interviews, and review of facility process and policy the facility failed to ensure that all transfer/discharge notifications were made for one resident (#176). The deficient practice could lead to notifications of resident transfer/ discharge not being made to all required parties.

Inspectors wroteBased on clinical record review, staff interviews, facility policy, and the Resident Assessment Instrument (RAI) manual, the facility failed to accurately complete a comprehensive Minimum Data Set (MDS) assessment within the required timeframe for one resident (#34). The deficient practice could result in delayed identification of potential risks and care needs.

Inspectors wroteBased on review of the clinical record, staff interviews, facility documentation, policy and procedure, the facility failed to ensure that one resident's (#34) cognitive communication deficit was appropriately care planned and implemented. The deficient practice could result in a plan of care that does not meet the resident's needs.

Inspectors wroteBased on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure a resident's comprehensive care plan was reviewed and revised to meet the resident's needs for one resident (#324). The deficient practice could lead a resident not receiving care and services to meet their needs, which could lead to harm or injury. -Findings Include: Resident #324 was re-admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, personal history of traumatic brain injury, dementia, unspecified abnormality of gait and mobility, cognitive communication deficit, anxiety disorder, and need for assistance with personal care. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) assessment that was not completed. [...]

Inspectors wroteBased on documentation, staff interviews, and facility policy and process, the facility failed to ensure pain medications as needed (PRN) was administered within the Pain Parameters for one resident (#54). The deficient practice could result in residents being overmedicated.

Inspectors wroteBased on clinical record review, interviews, facility documentation and policy, the facility failed to ensure that one resident (#94) did not receive medications against their wishes. This deficient practice can result in not respecting the rights of the resident.

Inspectors wroteBased on observations, interviews, facility documentation and policy, the facility failed to ensure that two of four sampled medication carts had medications stored according to professional standards. The deficient practice can result in cross-contamination of medications and medication errors.

Inspectors wroteBased on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure the medical record was complete and accurate for one resident (#324) The deficient practice could lead to care team members not being aware of a resident's status, and could lead to missed or delayed treatment. -Findings Include: Resident #324 was re-admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, personal history of traumatic brain injury, dementia, unspecified abnormality of gait and mobility, cognitive communication deficit, anxiety disorder, and need for assistance with personal care. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) assessment that was not completed. [...]

Inspectors wroteBased on observation, interviews, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure one resident (#2) was provided care and services to meet professional standards regarding following physician orders for assessment of a resident post-fall. The deficient practice could lead to an injury being missed and a delay of care provided to a resident.

Inspectors wroteBased on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure the medical record was complete, accurate, and readily accessible for one resident (#55). The deficient practice could lead to care team members not having accurate, complete, and current resident information to coordinate care, which could lead to a decreased quality of care for residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure that a resident received care and services according to physician orders regarding weight monitoring for one resident (#10). The deficient practice could result in a residents not receiving treatment to meet their needs.

Inspectors wroteBased on clinical record review, interviews, observations, policy review and the State Agency (SA) complaint tracking system, the facility failed to ensure that two residents (#1 and #2) received treatment and care in accordance with professional standards of practice by failing to provide wound care as ordered by a physician. The sample size was 5. The deficient practice could lead to residents acquiring wound infections.

Inspectors wroteBased on clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure a thorough investigation for a resident to resident complaint. The deficient practice could result in residents not being protected from further abuse and appropriate corrective action not taken.

Inspectors wroteBased on clinical record review, staff interviews, review of facility documentation, and policy, the facility failed to ensure that the electronic health record for resident #2 was complete and accurately documented. The deficient practice could result in incomplete and/or inaccurate clinical records.

Inspectors wroteBased on observations, resident and staff interviews, and policy and procedures, the facility failed to ensure that one resident (#41) received nail care as needed and showers, and one resident (#12) received assistance with showers as needed. The deficient practice could result in poor hygiene and infection.

Inspectors wroteBased on observations, staff and resident interviews, facility policy and procedures, and CMS (Centers for Medicare and Medicaid Certification) guidance, the facility failed to ensure that staff used appropriate enhanced barrier precautions (EBP) for two residents (#23 and #172). The deficient practice could result in the transmission of infections to residents and staff.

Inspectors wroteBased on clinical record review, staff interviews and facility policy review, the facility failed to ensure there was a physician order for the use of an indwelling catheter for one resident (#172). The deficient practice could result in inappropriate use of an indwelling catheter for residents who do not need them.

Inspectors wroteBased on staff interviews and facility policy, the facility failed to designate a qualified individual as the Infection Preventionist (IP) on an ongoing basis. The deficient practice could result in improper infection prevention practices in the facility.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedure, the facility failed to develop a complete baseline care plan that included the instructions needed to provide effective and person-centered care for three residents (#97, #102, and #147). The sample size was 19. The deficient practice could result in resident care needs not being met.

Inspectors wroteBased on observations, clinical record reviews, staff interviews, and review of policy and procedures, the facility failed to implement appropriate standard and transmission-based precautions. The deficient practice could result in transmission of infection.

Inspectors wroteBased on observations, resident and staff interviews, and review of the clinical record, the facility failed to ensure a resident (#98) had means to communicate with staff, by failing to ensure the call device was accessible to the resident. The sample size was 19. The deficient practice can result in residents' needs not being met in a timely manner.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedure, the facility failed to notify two residents (#1 and #45) and residents' representatives in writing of the reason for the transfer/discharge. The sample size was 2. The deficient practice could result in residents not knowing their discharge rights.

Inspectors wroteBased on clinical record reviews, staff interviews, and review of policy and procedure, the facility failed to notify the residents and/or the residents' representatives of the facility policy for bed hold at the time of discharge/transfer from the facility for two residents (#1 and #45). The sample size was 2. The deficient practice could result in residents not being informed of the bed hold policy.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#14) had a referral for a Level II PASRR (pre-admission screening and resident review form). The sample size was 2. The deficient practice could result in resident's not receiving needed care in the facility.

Inspectors wroteBased on clinical record review, staff interview, and review of facility policy and procedure, the facility failed to develop the person-centered care plan to include the resident's medication/medical needs for one resident (#14). The sample was 19. The deficient practice could result in an incomplete plan of care for the resident.

Inspectors wroteBased on clinical record review, and resident and staff interviews, the facility failed to fully assess one resident's (#97) nutritional status and needs by not obtaining a baseline weight. The sample size was two residents. The deficient practice could result in unmet nutritional needs and unidentified weight loss.

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, and policy review, the facility failed to ensure one resident (#14) had an order for oxygen use. The sample size was 2. The deficient practice could result in residents receiving oxygen without a physician order.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to complete behavior monitoring for one resident (#14). The sample size was 2. The deficient practice could result in the resident not receiving appropriate care and services to attain their highest practicable mental and psychosocial well-being.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure expired food was not available for consumption. The deficient practice could cause food-borne illness.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to develop and implement a policy to ensure two residents (#9 and #1) were administered influenza and pneumococcal immunizations. The sample size was 5. The deficient practice could result in residents not receiving immunizations.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to develop and implement policies and procedures to ensure two residents (#9 and #1) received the COVID vaccine. The sample size was 5. The deficient practice could result in residents not receiving the COVID vaccine per their request.

Inspectors wroteBased on clinical record review, staff interviews, and policy reviews, the facility failed to ensure one resident (#151) received the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) when there was an ending of Medicare services and the resident remained in the facility. The sample size was 3. The deficient practice could result in residents not being informed of their potential liability of payment.