14
Inspections
19
Deficiencies
2
Actual Harm or Above
5
Occurrences
April 1, 2026
Last Inspection
S/S D/E/F Potential for harmS/S G Actual harm
The most recent inspection of COTTONWOOD REHABILITATION AND HEALTHCARE CENTER on record is dated April 1, 2026. Across 14 published inspections, state surveyors cited 19 deficiencies, 2 of which reached actual harm or immediate jeopardy.
Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.
Provider Information
Status
Active
Facility Type
SNF (Medicare Only)
Administrator
Bradley, Christy Bernice
Owner
COTTONWOOD REHABILITATION AND HEALTHCARE CENTER LLC
Phone
(970) 516-1404
Payor Source
Medicare, Private Pay
City
DURANGO
ZIP
81301-7940
Inspections & Citations
14 inspections · 19 deficiencies4/1/2026Complaint Survey · ID 22CC80-H11 deficiency▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO2673355 was conducted on 4/1/26. One deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0684Quality of Care▼
Findings
Based on record review and interviews, the facility failed to provide services to ensure the residents highest practical physical wellbeing for two (#2 and #3) of four residents reviewed out of four sample residents. Specifically, the facility failed to ensure Resident #2 and Resident #3 had a physician's order to consume alcoholic beverages. Findings include:I. Facility policy and procedure The Alcoholic Beverages Policy, revised February 2023 was provided by the director of clinical services on 4/1/26 at 1:19 p.m. The policy read,“The purpose of this procedure is to establish uniform guidelines concerning the administration of alcoholic beverages. “A physician's order must be received before any alcoholic beverage may be administered to a resident. “Should such an order be received, the nurse supervisor receiving the order must contact the pharmacist to determine if any of the residents' current medications would interact with alcohol. “Should there be a medication that would interact with the alcohol, the nurse manager must inform the physician of such medications.“Record and follow the physician's instructions.”The Physician Orders Related to Activities policy, revised June 2018, was provided by the director of clinical services on 4/1/26 at 1:19 p.m. The policy read, “The facility obtains activities related to physician orders in a timely manner. “The activity director/coordinator reviews the physician’s orders upon admission during the activity assessment period, and within ‘progress’ or ‘change of condition’ reviews for the following areas which may impact activities such as: Consumption of alcohol (if alcohol was served or requested by a resident).”II. Resident #2A. Resident statusResident #2, age 71, was admitted on 8/3/23. According to the March 2026 computerized physician orders (CPO), diagnoses included multiple sclerosis, hypertension, osteoarthritis and depression. The 2/5/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He required maximum assistance with activities of daily living (ADL). B. Resident interview Resident #2 was interviewed on 4/1/26 at 10:30 a.m. Resident #2 said he attended happy hour at the facility and he drank alcoholic beverages on occasion when offered. He said residents had the right to make their own decisions to consume alcohol or have non-alcoholic beverages. C. Record reviewReview of Resident #2’s confidentiality, privacy and activities form, dated 9/25/24, revealed Resident #2 circled yes and gave permission to the facility staff to allow alcoholic beverages to be served to him during the facility’s Happy Hour activity if the physician agreed. The form documented a maximum of two alcoholic drinks would be allowed, per the physician’s order. Review of Resident #2’s comprehensive care plan, initiated 3/10/25, revealed there was no care plan focus for Resident #2’s alcohol consumption. Review of Resident #2’s March 2026 CPO revealed no physician’s order that indicated Resident #2 was able to consume alcohol. III. Resident #3 A. Resident statusResident #3, age 77, was admitted on 11/30/25. According to the March 2026 CPO, diagnoses included chronic respiratory failure, hypertension, dementia, mild with anxiety disorder and depression. The 1/26/26 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of 11 out of 15. She required substantial maximum assistance with ADLs. B. Resident interviewResident #3 was interviewed on 4/1/26 at 11:35 a.m. Resident #3 said she attended happy hour weekly and enjoyed going to have alcoholic beverages and to socialize with others. She said not all residents had alcoholic beverages, but she preferred to. C. Record reviewReview of Resident #3’s confidentiality, privacy and activities form, dated 9/25/24, revealed Resident #3 circled yes and gave permission to the facility staff to allow alcoholic beverages to be served to her during the facility’s Happy Hour activity if the physician agreed. A maximum of two alcoholic drinks would be allowed, per the physician’s order. The psychosocial care plan, initiated 3/11/25 and revised 3/24/26, revealed Resident #3 had a history of alcohol abuse and dependency and the resident was in remission from alcoholism. The care plan revealed Resident #3 was at risk of an impaired psychiatric mood related to the diagnosis of depression, history of alcohol dependency and anxiety. Review of Resident #3’s March 2026 CPO revealed no physician’s order that indicated Resident #3 was able to consume alcoholic beverages. IV. Staff interviews The activities director (AD) was interviewed on 4/1/26 at 11:00 a.m. The AD said the facility’s happy hour activity took place every Thursday. She said alcoholic beverages and non-alcoholic beverages were served to the residents. The AD said residents were offered whatever they preferred to drink. She said a variety of alcoholic drinks were served, with a maximum of two drinks for each resident. The AD said upon admission to the facility, residents were asked about their preference to consume alcoholic beverages or not. She said the social services director (SSD) assisted residents to complete the alcoholic beverages preference form and the information was shared with activities if a resident was not allowed to consume alcohol. The AD said she did not have a list of residents who could or could not have alcohol. She said it was up to the residents to decide if they wanted alcohol or not. The interim SSD was interviewed on 4/1/26 at 12:02 p.m. The interim SSD said an evaluation for the consumption of alcoholic beverages was completed with residents as part of the admission packet when they were admitted to the facility. He said a care plan was completed if a resident had a history of alcohol abuse and the information was shared with the activities director and management. The interim SSD said residents had the right to consume alcohol. He said the physician was made aware if a resident had a history of alcohol abuse, in case the alcohol could interfere with certain medications or in case staff needed to be monitoring residents for any alcoholic withdrawal concerns. The interim SSD said the facility did not track residents’ intake of alcoholic beverages because consumption happened one time a week at happy hour and not on a daily basis. Registered nurse (RN) #1 was interviewed on 4/1/26 at 12:45 p.m. RN #1 said the physician gave orders when a resident wanted to consume alcoholic beverages. The director of clinical service nurse was interviewed on 4/1/26 at 12:15p.m. The director of clinical services said residents should have a physician's order to consume alcoholic beverages. She said the physician’s order should include parameters for the amount of alcohol and risks with any medications the resident took. She said she was not part of the evaluations for residents to have alcohol, but she said had started an audit to identify which residents consumed alcoholic beverages (during the survey). She said she would look at the residents’ physician’s orders and would discuss it in the interdisciplinary team (IDT )meeting. The interim nursing home administrator (NHA) was interviewed on 4/1/26 at 12:30p.m. The interim NHA said there was no documentation revealing education was completed on the effects of consuming alcoholic beverages for Resident #2 and Resident #3. The medical director (MD) was interviewed on 4/1/26 at 4:15 p.m. The MD said he would prefer for no residents to consume alcoholic beverages, but as a physician, he respected the autonomy of the residents’ choice to consume alcohol if they chose to do so. He said when the resident had red flags or big issues, such as they were a fall risk, had dementia or was a known alcoholic, he would not give orders for those residents to consume alcoholic beverages. He said the facility had a physician’s order set in the facility’s electronic charting system which allowed nursing staff to add the physician’s order to consume alcohol into a resident’s electronic medical record (EMR), when appropriate. He said it was up to the facility to alert him when a physician’s order was needed for the resident. He said he had discussed with residents before why drinking alcohol was a bad decision but he said he had not discussed this with any current residents at the facility that he could recall. He said he relied on the director of nursing (DON) to notify him with any resident alcohol consumption concerns.
Plan of correction · submitted by the facility
Corrective action:On 4-20-2026 resident #2 orders were reviewed to ensure there was a physician’s order to consume alcoholic beverages. On 4-20-2026 a physician order was obtained for resident #3 to consume alcohol beverages. Others Affected:An audit was completed on 4-1-2026 to ensure all residents that consume alcoholic beverages had a physician's order to consume alcoholic beverages. 10 residents were found to be affected by this deficient practice. All 10 residents affected by this deficient practice obtained physician's order to consume alcoholic beverages. Systematic change:Upon admission Activity Director or designee will interview resident and or representative to complete the “Admission Alcohol Preference Questionnaire” to determine alcohol consumption preference. This document will consist of Yes or NO I wish to receive alcoholic beverage during happy hour, resident/representative signature and date. Bottom section filled out by facility representative of document will contain yes or no answers for PHYSICIAN PERMISION, PHYSICIAN ORDER COMPLETED IN POINTCLICKCARE, CARE PLAN COMPLETED FOR PREFERENCE ON ALCOHOL, Facility representative signature and date of completion. Monitoring Plan:Administrator or designee will complete audit form that contains: resident name, date of admission, alcohol preference to receive alcohol, if yes, was physician notified to obtain order and date care plan was updated. This audit will be completed one time a week for 4 weeks and then monthly for 2 months or until substantial compliance is met. Audit will be reviewed monthly at QAPI times 3 months or until substantial compliance is met.
4/1/2026Licensure Complaint Survey · ID 22CC83-H11 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A survey prompted by #CO2714685 was completed on 4/1/26. One deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0701Resident Care - Overall Care of the Residents▼
Findings
Based on record review and interviews, the facility failed to provide services to ensure the residents highest practical physical wellbeing for two (#2 and #3) of four residents reviewed out of four sample residents. Specifically, the facility failed to ensure Resident #2 and Resident #3 had a physician's order to consume alcoholic beverages. Findings include:I. Facility policy and procedure The Alcoholic Beverages Policy, revised February 2023 was provided by the director of clinical services on 4/1/26 at 1:19 p.m. The policy read,“The purpose of this procedure is to establish uniform guidelines concerning the administration of alcoholic beverages. “A physician's order must be received before any alcoholic beverage may be administered to a resident. “Should such an order be received, the nurse supervisor receiving the order must contact the pharmacist to determine if any of the residents' current medications would interact with alcohol. “Should there be a medication that would interact with the alcohol, the nurse manager must inform the physician of such medications.“Record and follow the physician's instructions.”The Physician Orders Related to Activities policy, revised June 2018, was provided by the director of clinical services on 4/1/26 at 1:19 p.m. The policy read, “The facility obtains activities related to physician orders in a timely manner. “The activity director/coordinator reviews the physician’s orders upon admission during the activity assessment period, and within ‘progress’ or ‘change of condition’ reviews for the following areas which may impact activities such as: Consumption of alcohol (if alcohol was served or requested by a resident).”II. Resident #2A. Resident statusResident #2, age 71, was admitted on 8/3/23. According to the March 2026 computerized physician orders (CPO), diagnoses included multiple sclerosis, hypertension, osteoarthritis and depression. The 2/5/26 comprehensive assessment revealed the resident was cognitively intact. He required maximum assistance with activities of daily living (ADL). B. Resident interview Resident #2 was interviewed on 4/1/26 at 10:30 a.m. Resident #2 said he attended happy hour at the facility and he drank alcoholic beverages on occasion when offered. He said residents had the right to make their own decisions to consume alcohol or have non-alcoholic beverages. C. Record reviewReview of Resident #2’s confidentiality, privacy and activities form, dated 9/25/24, revealed Resident #2 circled yes and gave permission to the facility staff to allow alcoholic beverages to be served to him during the facility’s Happy Hour activity if the physician agreed. The form documented a maximum of two alcoholic drinks would be allowed, per the physician’s order. Review of Resident #2’s comprehensive care plan, initiated 3/10/25, revealed there was no care plan focus for Resident #2’s alcohol consumption. Review of Resident #2’s March 2026 CPO revealed no physician’s order that indicated Resident #2 was able to consume alcohol. III. Resident #3 A. Resident statusResident #3, age 77, was admitted on 11/30/25. According to the March 2026 CPO, diagnoses included chronic respiratory failure, hypertension, dementia, mild with anxiety disorder and depression. The 1/26/26 comprehensive assessment revealed the resident was moderately cognitively impaired. She required substantial maximum assistance with ADLs. B. Resident interviewResident #3 was interviewed on 4/1/26 at 11:35 a.m. Resident #3 said she attended happy hour weekly and enjoyed going to have alcoholic beverages and to socialize with others. She said not all residents had alcoholic beverages, but she preferred to. C. Record reviewReview of Resident #3’s confidentiality, privacy and activities form, dated 9/25/24, revealed Resident #3 circled yes and gave permission to the facility staff to allow alcoholic beverages to be served to her during the facility’s Happy Hour activity if the physician agreed. A maximum of two alcoholic drinks would be allowed, per the physician’s order. The psychosocial care plan, initiated 3/11/25 and revised 3/24/26, revealed Resident #3 had a history of alcohol abuse and dependency and the resident was in remission from alcoholism. The care plan revealed Resident #3 was at risk of an impaired psychiatric mood related to the diagnosis of depression, history of alcohol dependency and anxiety. Review of Resident #3’s March 2026 CPO revealed no physician’s order that indicated Resident #3 was able to consume alcoholic beverages. IV. Staff interviews The activity director (AD) was interviewed on 4/1/26 at 11:00 a.m. The AD said the facility’s happy hour activity took place every Thursday. She said alcoholic beverages and non-alcoholic beverages were served to the residents. The AD said residents were offered whatever they preferred to drink. She said a variety of alcoholic drinks were served, with a maximum of two drinks for each resident. The AD said upon admission to the facility, residents were asked about their preference to consume alcoholic beverages or not. She said the social services director (SSD) assisted residents to complete the alcoholic beverages preference form and the information was shared with activities if a resident was not allowed to consume alcohol. The AD said she did not have a list of residents who could or could not have alcohol. She said it was up to the residents to decide if they wanted alcohol or not. The interim SSD was interviewed on 4/1/26 at 12:02 p.m. The interim SSD said an evaluation for the consumption of alcoholic beverages was completed with residents as part of the admission packet when they were admitted to the facility. He said a care plan was completed if a resident had a history of alcohol abuse and the information was shared with the activities director and management. The interim SSD said residents had the right to consume alcohol. He said the physician was made aware if a resident had a history of alcohol abuse, in case the alcohol could interfere with certain medications or in case staff needed to be monitoring residents for any alcoholic withdrawal concerns. The interim SSD said the facility did not track residents’ intake of alcoholic beverages because consumption happened one time a week at happy hour and not on a daily basis. Registered nurse (RN) #1 was interviewed on 4/1/26 at 12:45 p.m. RN #1 said the physician gave orders when a resident wanted to consume alcoholic beverages. The director of clinical service nurse was interviewed on 4/1/26 at 12:15p.m. The director of clinical services said residents should have a physician's order to consume alcoholic beverages. She said the physician’s order should include parameters for the amount of alcohol and risks with any medications the resident took. She said she was not part of the evaluations for residents to have alcohol, but she said had started an audit to identify which residents consumed alcoholic beverages (during the survey). She said she would look at the residents’ physician’s orders and would discuss it in the interdisciplinary team (IDT )meeting. The interim nursing home administrator (NHA) was interviewed on 4/1/26 at 12:30p.m. The interim NHA said there was no documentation revealing education was completed on the effects of consuming alcoholic beverages for Resident #2 and Resident #3. The medical director (MD) was interviewed on 4/1/26 at 4:15 p.m. The MD said he would prefer for no residents to consume alcoholic beverages, but as a physician, he respected the autonomy of the residents’ choice to consume alcohol if they chose to do so. He said when the resident had red flags or big issues, such as they were a fall risk, had dementia or was a known alcoholic, he would not give orders for those residents to consume alcoholic beverages. He said the facility had a physician’s order set in the facility’s electronic charting system which allowed nursing staff to add the physician’s order to consume alcohol into a resident’s electronic medical record (EMR), when appropriate. He said it was up to the facility to alert him when a physician’s order was needed for the resident. He said he had discussed with residents before why drinking alcohol was a bad decision but he said he had not discussed this with any current residents at the facility that he could recall. He said he relied on the director of nursing (DON) to notify him with any resident alcohol consumption concerns.
Plan of correction · submitted by the facility
Corrective action:On 4-20-2026 resident #2 orders were reviewed to ensure there was a physician’s order to consume alcoholic beverages. On 4-20-2026 a physician order was obtained for resident #3 to consume alcohol beverages. Others Affected:An audit was completed on 4-1-2026 to ensure all residents that consume alcoholic beverages had a physician's order to consume alcoholic beverages. 10 residents were found to be affected by this deficient practice. All 10 residents affected by this deficient practice obtained physician's order to consume alcoholic beverages. Systematic change:Upon admission Activity Director or designee will interview resident and or representative to complete the “Admission Alcohol Preference Questionnaire” to determine alcohol consumption preference. This document will consist of Yes or NO I wish to receive alcoholic beverage during happy hour, resident/representative signature and date. Bottom section filled out by facility representative of document will contain yes or no answers for PHYSICIAN PERMISION, PHYSICIAN ORDER COMPLETED IN POINTCLICKCARE, CARE PLAN COMPLETED FOR PREFERENCE ON ALCOHOL, Facility representative signature and date of completion. Monitoring Plan:Administrator or designee will complete audit form that contains: resident name, date of admission, alcohol preference to receive alcohol, if yes, was physician notified to obtain order and date care plan was updated. This audit will be completed one time a week for 4 weeks and then monthly for 2 months or until substantial compliance is met. Audit will be reviewed monthly at QAPI times 3 months or until substantial compliance is met.
5/15/2025Complaint Survey · ID 8YP611No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO39963 was conducted on 5/13/25 to 5/15/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
1/22/2025Revisit: Recertification Survey · ID LOUT22No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required.
Plan of correction
The state did not require a plan of correction for this citation.
9999FINAL OBSERVATIONSSurveyor note▼
Findings
The state listed this citation without publishing narrative text.
Plan of correction
The state did not require a plan of correction for this citation.
1/6/2025Revisit: Recertification Survey · ID LOUT12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 1/6/25 for all previous deficiencies cited on 11/21/24. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
12/11/2024Recertification Survey · ID LOUT216 deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag # K 000) are informational only and represent the facility's general characteristics. The facility is a 37,050-square-foot facility consisting of 40 resident rooms and supporting services. It is a one-story, slab-on-grade, without a basement, Type II (111) construction. It is classified as fully protected by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system. The facility is licensed for 40 beds and operated as a non-secured facility at the time of this survey; the census on the day of the survey was 35 residents. This Life Safety Code survey was conducted on December 11, 2024, for compliance with NFPA 101 Life Safety Code, 2012, Chapter 19, Existing Healthcare Occupancies; NFPA 99 Health Care Facilities Code, 2012 edition; and referenced publications.
Plan of correction
The state did not require a plan of correction for this citation.
0321Hazardous Areas - EnclosureS/S F▼
Findings
Through observation during the survey, it was determined that the facility failed to maintain hazardous areas in accordance with NFPA 101. This was evidenced by:1) The maintenance office deemed hazardous needs door closure2) The janitor closet main needs to reinstall the door closure 3) The kitchen mechanical room needs fire sealant around ceiling penetrations4) The furnace mechanical room needs the ceiling repaired, smoke-tight NFPA 101 19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4. NFPA 101 19.3.2.1.3 The doors shall be self-closing or automatic-closing. NFPA 101 4.6.12 Maintenance, Inspection, and Testing. 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 4.6.12.2 No existing life safety feature shall be removed or reduced where such feature is a requirement for new construction. 4.6.12.3* Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed. 4.6.12.4 Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. 4.6.12.5 Maintenance, inspection, and testing shall be performed under the supervision of a responsible person who shall ensure that testing, inspection, and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction. This deficiency could affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the facility maintenance director during the exit conference.
Plan of correction · submitted by the facility
Tag 0321NFPA 101 19.3.2.1.2*Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4. NFPA 101 19.3.2.1.3The doors shall be self-closing or automatic-closing. NFPA 101 4.6.12 Maintenance, Inspection, and Testing. 4.6.12.1Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. Corrective Action1) The maintenance office deemed hazardous and self closing hinges ordered and installed on 12/23/2024. Door tested and recorded to be closing with positive latch. 2) self closer on the janitor closet main ordered on 12/16/2024 and will be reinstalled when it arrives. Self closing spring hinges installed on 12/16/2024 to ensure door function until appropriate door closer arrives. 3) The kitchen mechanical room has been repaired with proper fire sealant where water supply and combustion air vent penetrate ceiling. 4) The furnace mechanical room ceiling has been repaired to ensure room is smoke-tight so that the fire suppression, and smoke detector function properly. Identifications of others. This deficient practice could affect occupants, including residents, staff, and visitors within the entire facility. Systematic ChangeAreas within the facility deemed hazardous will be inspected and documented monthly to ensure proper function of self-closing doors and all related hardware. Fire barriers and smoke barriers will be inspected and documented monthly to ensure that Appropriate rooms are smoke/fire tight. MonitoringEvery month Maintenance director or other appropriate staff will inspect all hazardous areas to ensure doors are self-closing and properly latching. This will be documented for each area. All findings will be covered during Monthly QAPI meeting. Newly installed hardware will be inspected and documented weekly for the first 3 months to ensure equipment is functioning properly, all findings will be reviewed in monthly QAPI meeting. Every month fire/smoke barriers will be inspected, and findings will be documented. all findings will be reviewed during monthly QAPI meeting. Newly repaired areas will be inspected weekly for the first 3 months to ensure repairs are in good condition. All findings will be reviewed monthly
0353Sprinkler System - Maintenance and TestingS/S D▼
Findings
Through document review and observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13. This was evidenced by1) The hydraulic information plate is incorrect and needs to reflect the proper design criteria from the drawings. It also lacks a general information sign. NFPA 101, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 5.2 Inspection. 5.2.6* Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible. 5.2.8* Information Sign. The information sign shall be inspected annually to verify that it is securely attached and is legible. NFPA 13, 24.6 General Information Sign. 24.6.1 The installing contractor shall provide a general information sign used to determine system design basis and information relevant to the inspection, testing, and maintenance requirements required by NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 24.6.1.1 Such general information shall be provided with a permanently marked weatherproof metal or rigid plastic sign secured with corrosion-resistant wire, chain, or other acceptable means. 24.6.1.2 Such signs shall be placed at each system control riser, antifreeze loop, and auxiliary system control valve. 24.6.2 The sign shall include the following information:(1) Name and location of the facility protected(2) Occupancy classification(3) Commodity classification(4) Presence of high-piled and/or rack storage(5) Maximum height of storage planned(6) Aisle width planned(7) Encapsulation of pallet loads(8) Presence of solid shelving(9) Flow test data(10) Presence of flammable/combustible liquids(11) Presence of hazardous materials(12) Presence of other special storage(13) Location of auxiliary drains and low point drains on dry-pipe and preaction systems(14) Original results of main drain flow test(15) Name of installing contractor or designer(16) Indication of presence and location of antifreeze or other auxiliary systems
Plan of correction · submitted by the facility
Tag 0353NFPA 101, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 13, 24.6 General Information Sign. 24.6.1 The installing contractor shall provide a general information sign used to determine system design basis and information relevant to the inspection, testing, and maintenance requirements required by NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Corrective ActionCooper fire arrived at cottonwood RHC facility on 12/16/2024 to assess appropriate signage needed, and to ensure that signage is accurate and up to date. General information sign containing the fallowing: (1) Name and location of the facility protected(2) Occupancy classification(3) Commodity classification(4) Presence of high-piled and/or rack storage(5) Maximum height of storage planned(6) Aisle width planned(7) Encapsulation of pallet loads(8) Presence of solid shelving(9) Flow test data(10) Presence of flammable/combustible liquids(11) Presence of hazardous materials(12) Presence of other special storage(13) Location of auxiliary drains and low point drains on dry-pipe and preaction systems(14) Original results of main drain flow test(15) Name of installing contractor or designer(16) Indication of presence and location of antifreeze or other auxiliary systemsHas been requested from Cooper fire and will be installed upon arrival. Identifications of others. All residents have potential for harm from this deficient practice. Systematic ChangeSignage will be checked and documented during monthly visual sprinkler room inspections. MonitoringMonthly signage Inspection results will be reviewed monthly in QAPI to ensure proper placement and appropriate signs with accurate information.
0521HVACS/S F▼
Findings
Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 80, and 105. This was evidenced by:1) Fire Dampers (4-6 years)(101 8.5.5.4.1 & 80 19.4): Not ProvidedNFPA 101 8.5.5.4.1 Air-conditioning, heating, ventilating ductwork, and related equipment, including smoke dampers and combination fire and smoke dampers, shall be installed in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, and NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. NFPA 80 19.4* Periodic Inspection and Testing. 19.4.1 Each damper shall be tested and inspected 1 year after installation. 19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. NFPA 105 6.5 Periodic inspection and testing. 6.5.1 Smoke dampers for dedicated and non-dedicated smoke control systems shall be inspected and tested in accordance with NFPA92A, Standard for Smoke-Control Systems Utilizing Barriers and Pressure Differences. 6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. This deficiency can potentially affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the facility maintenance director during the exit conference.
Plan of correction · submitted by the facility
Tag 0521NFPA 101 8.5.5.4.1 Air-conditioning, heating, ventilating ductwork, and related equipment, including smoke dampers and combination fire and smoke dampers, shall be installed in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, and NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. NFPA 80 19.4* Periodic Inspection and Testing. 19.4.1 Each damper shall be tested and inspected 1 year after installation. 19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. Corrective ActionVents inspected for fire dampers. All dampers discovered have been visually inspected for proper function and compliance. replacement fusible links ordered 12/30/2024 for testing. All dampers will be function tested by 1/16/2024. Identifications of othersThis deficient practice can potentially affect occupants, including residents, staff, and visitors within the entire facility. Systematic ChangeDamper inspections and Testing completed and documented. Periodic inspection and testing now added to Tels to ensure inspections are completed. In accordance with NFPA 101. MonitoringDamper inspection will be reviewed monthly in QAPI to ensure completion and to determine when next inspection is due.
0711Evacuation and Relocation PlanS/S F▼
Findings
Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) Fire Safety Plan (101 19.7.2.2): This plan was not provided per NFPA 101 requirements, and the evacuation maps do not show smoke compartment walls. NFPA 101 19.7.1 Evacuation and Relocation Plan and Fire Drills. 19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. NFPA 101 19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:(1)Use of alarms(2)Transmission of alarms to fire department(3)Emergency phone call to fire department(4)Response to alarms(5)Isolation of fire(6)Evacuation of immediate area(7)Evacuation of smoke compartment(8)Preparation of floors and building for evacuation(9)Extinguishment of fireNFPA 101 This deficiency can potentially affect occupants, including residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.
Plan of correction · submitted by the facility
Tag 0711NFPA 101 19.7.1 Evacuation and Relocation Plan and Fire Drills. 19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. Corrective ActionCottonwoods evacuation maps have been updated to show the 4 smoke compartments, and walls/doors that separate them in addition to pre existing evacuation routs. The fire plan has been simplified and updated to reflect these maps. Fire safety plan now elaborates on alarm activation means (automatic and manual activation). How and when to activate alarms. How our alarm system transmits signal to the fire department. As well as who is responsible for calling the fire department after alarm is activated. The plan also elaborates on all staff responsibility after fire is identified, and/or when alarm is activated. This includes: isolating the fire by closing doors and windows. evacuation of staff, residents, and visitors in the immediate area. When it is appropriate and steps to safely attempt to extinguish the fire. Evacuating the smoke compartment, (i.e., how to transport residents, give directions, and where is a safe location to evacuate to. Staff will be educated on these changes during all staff meeting on January 16th 2025, all new hires will be educated on this upon hire and full staff annual. Identifications of othersThis deficient practice can potentially affect occupants, including residents, staff, and visitors within the entire facility. Systematic ChangeFire plan will be updated, and staff notified of any changes to reflect best practices upon recommendations from qualified professionals. Plan will be reviewed quarterly to ensure they are up to date and signs are placed appropriately with appropriate information identified on the map. MonitoringMaps and fire plan will be audited on/ before monthly QAPI meeting for the first 3 months the quarterly after that. Findings will be covered During monthly QAPI meeting.
0741Smoking RegulationsS/S E▼
Findings
Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) Smoking (101 19.7.4): There are designated areas; however, during the survey, it was seen that staff are not using the designated areas with approved trash and cigarette receptacles. We need to make this area designated and compliant or have staff smoke in approved areas. NFPA 101 19.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:(1)Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.(2)In healthcare occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.(3)Smoking by patients classified as not responsible shall be prohibited.(4)The requirement of 19.7.4(3) shall not apply where the patient is under direct supervision.(5)Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.(6)Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. This deficiency could affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the facility maintenance director during the exit conference.
Plan of correction · submitted by the facility
Tag 0741NFPA 101 19.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:(1)Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.(2)In healthcare occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.(3)Smoking by patients classified as not responsible shall be prohibited.(4)The requirement of 19.7.4(3) shall not apply where the patient is under direct supervision.(5)Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.(6)Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. Corrective ActionStaff educated on appropriate smoking location and dedicated smoking location regulations. All staff education will be provided on 1/16/2025 for all current staff. All new staff will be educated upon hire, and smoking regulations will be covered annually during all staff Inservice. Identifications of othersThis deficient practice could affect occupants, including residents, staff, and visitors within the entire facility. Systematic ChangeAll staff will be given and sign a copy of the facility smoking policy that clearly states safe location and regulations on smoking. Any staff found smoking out side of the designated smoking location will receive a progressive disciplinary warning starting with a verbal warning and education, and after 3 violations ending in possible termination of employment. MonitoringDuring monthly QAPI meeting all signed smoking policies will be reviewed. To ensure all staff have received appropriate education.
0914Electrical Systems - Maintenance and TestingS/S F▼
Findings
Through document review during the survey, it was determined that the facility failed to maintain the electrical systems in accordance with NFPA 99. This was evidenced by:1) Receptacle Testing (99 6.3.4.1): The record does not meet NFPA 99 requirementsNFPA 996.3.4.2 Record Keeping. 6.3.4.2.1* General. 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modifications. 6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. This deficiency could affect occupants, including residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.
Plan of correction · submitted by the facility
Tag 0914NFPA 996.3.4.2 Record Keeping. 6.3.4.2.1* General. 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modifications. 6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. Corrective ActionNew testing form created. This form covers GFCI testing (pass/fail), polarization (pass/fail), and receptacle retention (specific measurement/ pass fail). Identifications of othersThis deficient practice could affect occupants, including residents, staff, and visitors within the entire facility. Systematic Changeany time retention testing of outlets is completed specific retention will be measured and recorded then marked as pass or fail based on the findings. MonitoringReceptacle Retention will be tested and recorded as needed and annually. Task and appropriate documentation Added to tels. This document will be reviewed monthly During QAPI meeting and recorded on an audit form.
9999FINAL OBSERVATIONSSurveyor note▼
Findings
Christmas decorations: destructive testing. We tested multiple decorations and found that 1 green garland was not being treated properly. This garland was removed before the survey ended.
Plan of correction
The state did not require a plan of correction for this citation.
11/21/2024Recertification Survey · ID LOUT112 deficiencies▼
0000Initial CommentsSurveyor note2 building records▼
Findings · record 1 of 2
A recertification survey was conducted from 11/18/24 to 11/21/24. Two deficiencies were cited.
Findings · record 2 of 2
An Emergency Preparedness survey was conducted from 11/18/24 to 11/21/24. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0740Behavioral Health ServicesS/S D▼
Findings
Based on record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for one (#14) of three residents reviewed for behavioral and emotional status out of 22 sample residents. Specifically, the facility failed to coordinate timely necessary behavioral, mental and emotional health care and services for Resident #14. Findings include: I. Resident #14 A. Resident status Resident #14, age 65, was admitted on 11/3/23. According to the November 2024 computerized physician orders (CPO), diagnoses included Arnold-Chiari syndrome with hydrocephalus (a condition where the lower part of the brain protrudes into the spinal canal causing a blockage in the flow of cerebrospinal fluid and leading to a buildup of fluid in the brain), anxiety disorder, depression, insomnia, other complicated headache syndrome, cognitive communication deficit, unspecified dementia, severe, with mood disturbance and malignant neoplasm of prostate. The 9/17/24 minimum data set (MDS) assessment revealed the resident's cognition was severely impaired with a brief interview for mental status (BIMS) score of four out of 15. Verbal behavioral symptoms directed towards others were present during the assessment. He used a wheelchair for mobility and required partial moderate assistance with toileting hygiene, substantial/maximal assist with bathing and partial/moderate assist with transfers. He was prescribed antianxiety and antidepressant medications. B. Record review A review of the comprehensive care plan, initiated on 11/14/23 and revised on 11/20/24, revealed Resident #14 had a history of depression and insomnia and was taking two antidepressant medications (Trazodone and Lexapro) due to sleep disturbances, withdrawal from activities and refusals of care. He received Ativan for anxiety as evidenced by restlessness and leg movements, pacing, increases in complaints, agitation, obsession about clothing and temperature changes, false accusations against staff, and playing with a suprapubic urinary catheter. Resident #14 was prescribed and administered an antipsychotic medication (Seroquel) related to auditory hallucinations, increased agitation and anxiety. Interventions included referral to a psychologist/psychiatrist as needed. Review of Resident #14's behavior care plan, initiated on 5/16/24 and revised on 11/18/24, revealed the resident had behaviors related to his dementia diagnosis and often made false allegations and statements. The resident yelled and cussed at staff, residents and imaginary individuals and often had auditory hallucinations. He was withdrawn from group activities and stayed in his room most of the day. He had depression at times that caused him to have difficulty sleeping as evidenced by sleep disturbances and restless leg movements. Interventions included administering medications per the physician's order, approaching the resident in a calm manner to avoid frustration and behavior escalation, attempting to redirect the resident when he was exhibiting behaviors, monitoring and documenting episodes of inappropriate behaviors, monitoring the resident's behavior episodes and attempting to determine the underlying cause of the behavior, including considering location, time of day, persons involved and situations, observing and reporting any changes in mental status caused by situational stressors and offering psychologist/psychiatrist services as needed. Review of Resident #14's November 2024 CPO revealed the following physician's orders:Trazodone HCl oral tablet 50 milligrams (mg). Give 25 mg by mouth at bedtime for insomnia and depression, ordered 11/23/23. Cymbalta oral capsule delayed release particles 20 mg (Duloxetine HCl). Give one capsule by mouth one time a day for depression, ordered 11/4/23 and discontinued on 10/31/24. Escitalopram Oxalate (Lexapro tablet 20mg). Give one tablet by mouth one time a day for depression, ordered 11/1/24. Ativan (Lorazepam) oral tablet 1 mg. Give one tablet by mouth at bedtime related to generalized anxiety, ordered 5/7/24. Quetiapine Fumarate Oral Tablet 25 mg. Give one tablet by mouth three times a day for unspecified dementia, severe, with mood disturbance, ordered 11/14/24. A nurse progress note dated 4/7/24 documented Resident #14 had been angry that he was not served breakfast immediately when entering the dining room. The resident was reminded that the cooking staff did not arrive to work until 6:00 a.m., therefore they were unable to serve him at 5:00 a.m..The resident was yelling at his neighbor to 'shut-up', because his neighbor was whistling songs while getting ready for the day. A nurse progress note dated 4/9/24 documented the interdisciplinary team (IDT) met to review resident's psychotropic medication usage. The resident had no adverse side effects to the medications and no changes were made to the current medications per the power of attorney's (POA) and the resident's request. A risk versus benefit form was completed and the IDT would continue to review quarterly or PRN (as needed). A nurse progress note dated 4/16/24 documented Resident #14 had repeatedly set his call light off while laying in bed. When asked upon entering each time, what the nurse could do to assist him, he said his neighbor slammed the bathroom door, his sheet was coming off or he did not call. Upon the nurse entering his room the last time, the resident had thrown a dish from the kitchen on the floor and it shattered. Resident #14 had changed his shirt at least six times this morning (4/16/24). A nurse progress note dated 5/9/24 documented Resident #14 was upset that his neighbor shut his bathroom door loudly. The resident attempted twice to throw ice water into his neighbor's room and was very angry and difficult to redirect. A nurse progress note dated 5/13/24 documented Resident #14 said he was going to throw water at another resident's face. He was asked what made him so upset and he reported his neighbor was in the bathroom, slammed the doors and woke him up. The CNA (certified nurse aide) informed the resident it was his neighbor's shower and he was not creating excess noise on purpose. The resident said he was still going to throw water in his face. The CNA then asked the resident to give them 20 minutes, which he agreed to. No more threats had been made since and he was now in a pleasant mood. A nurse progress note dated 7/24/24 documented the IDT met to review Resident #14's psychotropic medication usage. The resident had had no adverse side effects to the medications and no changes were being made to the resident's current medications. The IDT would continue to review quarterly at the psychotropic committee meeting or PRN and plan GDRs (gradual dose reduction) as appropriate. Resident #14 and his POA requested that no changes be made to his medications because the medications were working for the resident. -The progress note did not indicate the facility offered a psychologist or psychiatrist consultation to the resident to help with the resident's behaviors. A nurse progress note dated 10/6/24 documented the staff was to monitor the resident for the following behaviors related to the use of Ativan as evidenced by an increase in complaints, obsession about clothing and temperature changes, false accusations against staff, playing with his catheter and refusals of care.-The progress note failed to identify interventions that were to be used with the resident to help the resident with the distressing behaviors. A progress note documented by the DON on 10/23/24 DON revealed Resident #14 pressed his call light five times in one minute. The resident was complaining his ears were ringing and he was not able to hear. He was given some eardrops but persisted in fixating on the concern and pressed his call light repeatedly for the same reason. He was requesting to have the physician come in and look in his ears. The note documented the resident had his television (TV) volume extremely loud and, though he claimed he could not hear, he was able to understand everything the DON and the CNAs were saying to him. The DON suggested he turn his TV volume down which could potentially help with his complaint of not being able to hear but the resident refused. Redirection continued without success and the DON notified the physician of the resident's request to look in his ears. A nurse progress note dated 10/24/24 documented Resident # 14 was agitated during the shift and asked to use the bathroom four times in 30 minutes. Staff would assist him to the bathroom every time, for him to sit down, stand right back up and say he was done. The resident was fixating on certain other residents being in the dining room and refusing to eat because they were in there. The resident had to be redirected to the dining room five times during the shift, after being placed at a table per his request, then stating 'that resident is down here' and turning around and leaving the dining room. The resident was difficult to redirect. A nurse progress note dated 10/28/24 documented the resident was yelling out at neighbors and staff to stop slamming the doors. Staff were mindful about closing the doors softly and he continued to yell when doors around him were shut as quietly as possible. Resident #14 was assured everyone was trying to keep the environment quiet, he was given fresh water and his medications at his preferred time. He continued to yell out after any sounds were made in the hall or neighboring rooms until he fell asleep. A nurse progress note dated 10/30/24 documented the resident was yelling loudly about people slamming doors. The nurse watched the resident's neighbor's door be shut with no slamming. The resident had continually used his call light when he was upset about loud noises and cold coffee. A nurse progress note dated 11/1/24 documented Resident #14 was repeatedly screaming 'be quiet' at the top of his lungs, as well as putting his call light on. The nurse informed the resident they would be as quiet as they could and he verbalized understanding. A nurse progress note dated 11/12/24 documented the resident had been yelling over any noise throughout the night. He yelled at another resident to shut up who was talking in the hallway on the way back to their room. Resident #14 was offered food and drink, efforts to keep his environment quiet and reassurance that no one was being noisy on purpose. The resident voiced his understanding, however the resident continued to yell at neighboring residents and staff from his room. A progress note documented by the DON on 11/14/24 documented Resident #14 had been extremely agitated, more so than his normal. He was yelling at his next door neighbor even though the resident was not in his room next door. Resident #14 had pushed his call light three times in five minutes and was yelling and agitated. He then pressed his call light another two times and when the CNA entered the room, he was yelling that the lady next door kept slamming the door, however, there was no lady next door. The physician was notified. A progress note documented by the DON on 11/15/24 documented the DON called the resident's family member to let her know the physician ordered Seroquel for the resident and to obtain consent for the medication. The family member gave consent for the medication. A nurse progress note dated 11/15/24 documented the resident was agitated, yelling, and cursing during the shift and refused a catheter change. The note documented the resident had begun taking Seroquel and was offered a quiet environment, food and drink and lotion was applied to his abdomen as requested for itchiness. A nurse progress note dated 11/19/24 documented the resident was yelling profanities from his room regarding another resident slamming her door, however, there were no residents slamming their doors. A nurse progress note dated 11/20/24 documented Resident #14 was again yelling and screaming about a resident slamming her door. There were no noises heard by staff who were outside his door being mindful of providing a quiet environment for the resident. The nurse apologized and told the resident the staff did not hear any loud noises or door slamming, but they would be more cautious of making noise. Resident #14 indicated the unoccupied room next to him was where the noise was coming from. A progress note documented by the social services director (SSD) on 11/21/24 (during the survey) documented a physician's order for a referral to behavioral psychiatric services for Resident #14 had been obtained. The resident's POA was contacted and agreed with the referral. The SSD attempted to schedule an appointment with a behavioral health services provider.-The progress note failed to indicate if the SSD was able to schedule a behavioral health services appointment.-Review of the progress notes from 4/7/24 through 11/21/24 revealed there was no documentation to indicate the facility assessed the underlying causes and potential triggers for Resident #14's expressions of distress.-There was no documentation in the resident's electronic medical record (EMR) to indicate the facility offered a psychologist or psychiatrist consultation for Resident #14 in order to assist the resident with his distressing behaviors until 11/21/24, despite several months of documentation related to the resident's behaviors (see progress notes above). II. Staff interviews Registered nurse (RN) #2 and CNA #1 were interviewed together on 11/18/24 at 2:01 p.m. RN #2 and CNA #1 said Resident #14 had exhibited his agitation and aggressive verbal behaviors towards staff and other residents for the past several months. RN #2 said Resident #14's behaviors were disturbing to other residents who were on the unit for skilled rehabilitation services and were going back to the community. RN #2 and CNA #1 said Resident #14 was not offered and had not received any psychological or psychiatric health care consultation or services. RN#1 was interviewed on 11/21/24 at 8:45 a.m. RN #1 said Resident #14's behaviors were consistent in the past few weeks and very disturbing to him and other residents. She said his behaviors were not specifically directed. She said the staff offered non-pharmacological interventions such as distractions, TV shows/sports, activities and offered to take the resident outside. She said the resident was not receiving any mental health services for his behaviors. The DON was interviewed on 11/21/24 at 11:10 a.m. The DON said Resident #14's behaviors had escalated within the last few weeks and she said the resident "did not feel good in his own skin." She said she communicated with the resident's POA, as well as his physician, regarding recent psychotropic medications changes. She said the physician wanted to try medications first. She said the facility did not consider a behavioral health consultation for the resident during the most recent psychotropic medications review with the medical director and the pharmacist. The DON said she would reach out to the resident's POA for an approval for a mental health consultation for the resident.
Plan of correction · submitted by the facility
F740- Behavioral health services. Each resident must receive, and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident’s whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. It is the practice of the facility to treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of state and federal law. Corrective Action On 11/21/2024, SSD (social service director) obtained consent from resident #14’s POA (power of attorney) to refer resident #14 to behavioral health services with Axis Mental Health. The receptionist at Axis Mental Health stated that the Senior Reach Team would be more appropriate. SSD called the Senior Reach team on 11/21 and left a voice mail. On 12/2 Axis Senior Reach Team returned the call for the appointment request and stated that the receptionist with Axis Mental Health should have set up the appointment, and that she would have the receptionist call the facility to schedule. On 12/6 SSD again reached out to Axis Mental Health to schedule the appointment and the receptionist stated that she would reach out to the Senior Reach Team to schedule an appointment and call back on 12/9 with the day and time. 12/10/2024 Received call back from Axis Mental Health, an appointment for resident #14 has been set up for 12/20/2024 @ 2pm. Identifications of othersSSD will audit all residents with patterned behaviors to ensure their recommended behavioral health care needs and/or services have been addressed by 12/15/2024. Any concerns identified will be corrected by 12/20/2024. SSD to audit all behavioral health care plans so ensure all recommendations and interventions are currently being or have been followed by 12/15/2024. Any concerns identified will be corrected by 12/20/2024. Systematic ChangeNHA (nursing home administrator)/designee will in-service SSD by 12/15/2024 on assessing, identifying, and addressing behavioral health care and behavioral health services needs of residents and ensuring recommendations are followed. MonitoringStarting 12/20/2024 SSD/designee will monitor with each new behavior and/or new/change in psychotropic medication, that the residents behavioral, mental, and emotional care needs are being met and that interventions are in place and being followed. Monitoring results will be documented on an audit form. Starting 12/20/2024 the NHA/designee will audit weekly during At Risk Review residents on a new or have a change in psychotropic medications, new admissions with behaviors and current residents with behaviors to ensure their behavioral, mental, and emotional care has been addressed and that interventions are in place and being followed. Monitoring results will be documented on an audit form. The NHA/designee and SSD/designee will track and trend the results of the audits and report their findings to the QAPI committee monthly. The QAPI committee will evaluate the effectiveness of the plan based on trends identified and implement additional interventions as needed to ensure compliance monthly for 3 months and then reassess the need for continued monitoring based on compliance.
0882Infection Preventionist Qualifications/RoleS/S F▼
Findings
Based on interviews and record review, the facility failed to employ an infection preventionist (IP) who had completed specialized training in infection prevention and control which had the potential to affect all residents residing in the facility at the time of the survey. Specifically, the facility failed to have a qualified IP involved with the facility's infection prevention and control program. Findings include: I. Facility policy and procedure The Infection Preventionist policy, revised September 2022, was provided by the nursing home administrator (NHA) on 11/21/24 at 8:25 a.m. The policy read in pertinent part, "The IP is professionally trained in nursing, medical technology, microbiology, epidemiology, or other related field with at least the following professional training:-A nurse must have earned a certificate/diploma in nursing; and,-A medical technologist must have earned at least an associate's degree in medical technology or clinical laboratory science. "The IP is employed on site and at least part time; and,-The IP is scheduled with enough time to properly assess, develop, implement, monitor, and manage the infection control program, address the training requirements, and participate in required committees." II. Record review A request was made for the IP's infection control certificate on 11/20/24 at 2:30 p.m. The director of nursing (DON) was unable to locate the IP certificate of completion. III. Staff interviews The DON was interviewed on 11/20/24 at 2:10 p.m. The DON said she had worked at the facility as a full time DON. She said she completed the required education in 2024 to obtain the infection control certificate but was unable to locate the certificate of completion. The DON said she worked in the facility as a full time DON but also functioned as the facility IP. The DON said she collected infection statistics but had not analyzed the information to ensure the infection control program was effective. The DON said she was unaware of the requirement for the facility to have a qualified infection preventionist that worked as an IP at least half time. The DON said the facility will review the requirement for the IP position and discuss the requirement with the NHA.
Plan of correction · submitted by the facility
F882 Infection preventionistThe facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility’s IPCP. The IP must:§483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;§483.80(b)(2) Be qualified by education, training, experience, or certification. It is the practice of the facility to treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of state and federal law. Corrective ActionPrevious IP (infection preventionist) present at the time of survey is no longer employed with Cottonwood RHC. Previous IP (infection preventionist) had completed 15 modules pertaining to IP (infection preventionist) but failed to attempt final exam for IP (infection preventionist) certification. New qualified IP (infection preventionist) hired with completed Co Train infection preventionist training as of 12/08/24. Proof of completion was provided and filed. Identifications of othersAll residents have the potential to be affected by this deficient practice. Systematic ChangeStarting 12/8/2024 all current or new IP (infection preventionists), will be required to obtain their IP (infection preventionist) training certificate within 14 days of hire. IP (infection preventionist) training and certification will be reviewed upon any position/ status changes of Current IP (infection preventionist) by NHAMonitoringStarting 12/8/2024, NHA/designee will confirm monthly that the designated IP (infection preventionist) certificate is current. The NHA/designee will track and trend the results of the audits and report their findings to the QAPI committee monthly. The QAPI committee will evaluate the effectiveness of the plan based on trends identified and implement additional interventions as needed to ensure compliance monthly for 3 months and then reassess the need for continued monitoring based on compliance.
1/30/2024Focused Infection Control, Other-Fed Survey · ID QA9M111 deficiency▼
0884Reporting - National Health Safety NetworkS/S F▼
Findings
Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/22/2024 and 01/28/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.
Plan of correction
The state did not require a plan of correction for this citation.
8/31/2023Revisit: Recertification Survey · ID NTJQ22No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.
Plan of correction
The state did not require a plan of correction for this citation.
8/30/2023Revisit: State Licensure Survey · ID EBHJ12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 8/29/23 for all previous deficiencies cited on 8/30/23. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
Reportable Occurrences
5 records8/7/2025Misappropriation of Property · ID 2502E994003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 8/7/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a misappropriation of property event. Reportedly, client (B) alleged someone used her credit card to make unauthorized charges back in July 2025. The family assisted the client in closing the account. During the course of the investigation, the healthcare entity conducted interviews. No alleged assailant was identified. The bank conducted an investigation into potential fraud. No other clients reported concerns about theft. The facility could not substantiate an allegation of fraud or financial exploitation. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 9/29/2025 · released to the public 10/6/2025.
2/3/2025Physical Abuse · ID 2502E994002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS: On 2/3/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a physical abuse event. Female client (B) alleged male client (A) struck her on the shoulder as he passed by causing her pain. During the course of the investigation, the healthcare entity kept the clients separated, conducted an assessment and interviews and started safety checks. No visible injury was observed yet she continued to report her shoulder really hurt. Client (A) reported a different version about the event saying he utilized her shoulder to help move around her; however, he confirmed she reported pain with the touch. No one witnessed the interaction. Due to conflicting statements, the facility was unable to determine if the act was intentional or not. Client (B) discharged home two days later and safety monitoring remained in place for client (A). The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 4/4/2025 · released to the public 4/11/2025.
5/23/2024Brain Injury · ID 2402E994001Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS: On 5/23/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a brain injury event. During the course of the investigation, the healthcare entity reported client (A) fell in the bathroom where he struck his head. He had complaints of pain and was transferred to the hospital for further evaluation. Diagnostic test results showed a brain bleed. He was transferred into hospice services where he passed away the following day. When reviewing the event, the facility determined he did not call for staff assistance and self ambulated to the bathroom where he fell with injury. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 3/4/2025 · released to the public 3/11/2025.
8/22/2023Diverted Drugs · ID 2302E994004Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE:
On 8/22/23, while a nurse manager reviewed an incident involving medications, count discrepancies were discovered with one nurses’ practice (nurse 2). Also during shift change this morning and when conducting medication counts today, the oncoming nurse (1) noted several .5 mg Lorazepam tablets were unaccounted for. Nurse (2 – off-going nurse) could not account for the discrepancy. The facility filed a report of alleged drug diversion involving nurse (2).
Management reviewed information from critical safety analysis reports (CSAR), pharmacy delivery sheets, and medication administration records. Management reported the following medications were identified as missing: 11.5 tablets of .5 mg Lorazepam, 28 tablets of 5 mg Oxycodone, three tablets of 50 mg Tramadol, one tablet of 5ml Hydrocodone, and 60 tablets of 5 mg Oxycodone.
FACILITY / AGENCY ACTION:
The facility conducted an internal investigation and notified the police. Management suspended the nurse (2). Review of CSAR logs showed nurse (2) misdated medication entries with times not matching their work schedule or assigned cart/hallway. The facility reported nurse (2) has been involved in other count discrepancies involving Oxycodone medication. Further review of nurse (2)’s clinical documentation showed they did not follow nursing standards of practice with medication administration or documentation expectations. One alert and oriented resident reported she did not request prn (as needed) Oxycodone despite nurse (2)’s documentation showing it was being administered per their request. To help support these findings, management reviewed call light records associated with the Oxycodone administration. The resident had not utilized the call light around the date and time of when nurse (2) documented the administrations. Other staff reported witnessing nurse (2) exhibiting erratic behaviors, appearing tired, and falling asleep during previous shifts. However, no one reported seeing the nurse (2) divert any medications. Based on poor nurse practice findings, staff interviews and medication discrepancies, the facility substantiated the allegation of nurse (2) diverting medications. Nurse (2)’s employment was terminated. and management reported nurse (2) to their prospective licensing board. The facility reported the police arrested nurse (2) for charges of alleged drug diversion. Following the investigation, the facility took the opportunity to provide re-education to all nursing staff on medication handling and nursing standards. In addition, management implemented an auditing plan to monitor nursing staff and medication management.
DEPARTMENT FINDINGS:
In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed.
The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.
Publication
Sent to facility 1/2/2024 · released to the public 1/9/2024.
6/23/2023Misappropriation of Property · ID 2302E994003Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE:
On 6/23/23, a resident, in his 90s, reported $350 from his wallet that was stored in his room. The wallet had not been secured.
FACILITY / AGENCY ACTION:
The facility conducted an internal investigation and notified the police, family/guardian, and physician. A lock box was provided to the resident, and he was encouraged to safeguard his valuables. No employee witnessed any money or any money being taken. The facility was unable to determine what happened to the money. Staff was reminded that upon admission, residents should be offered a key to lock box in closet or encourage family to take money or any valuables home with them.
DEPARTMENT FINDINGS:
In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed.
The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.
Publication
Sent to facility 9/25/2023 · released to the public 10/2/2023.