COTTONWOOD RIDGE

Description of how the licensee will correct the deficiencyThe facility will correct this deficiency by updating the resident agreements for Residents #1 and #4 and completing a 100 percent audit of all current resident records to ensure each resident has a current signed agreement. Any outdated or missing agreement identified during the audit will be updated and signed. The resident agreements were not updated annually because the facility did not have a tracking system in place and the Administrator was unaware of the annual update requirement. To prevent recurrence, the facility has implemented a resident agreement tracking log to track signature dates and annual renewal due dates. The Administrator is responsible for resident agreement compliance. In the Administrator’s absence, the Resident Care Coordinator will serve as the alternate. The Administrator and Resident Care Coordinator will be trained on the annual update requirement, the tracking process, and documentation expectations. Description of how the licensee will monitor the corrective actionThe Administrator or Resident Care Coordinator will monitor compliance by reviewing the tracking log and resident records to ensure agreements are current, signed, and updated annually. Monitoring will include a 100 percent review of the facility census monthly for a minimum of three months. Results will be documented on the tracking log or audit form, including any corrective action taken. Monitoring results will be reviewed through the facility’s quality assurance process (QAPI) for a minimum of three months. Any overdue, missing, or incomplete resident agreement identified during monitoring will be corrected immediately and followed by additional review or training as needed. Completion dateCompletion date: 3/27/26

The policy addresses prevention, reporting, response, treatment, documentation, and follow-up related to insects, rodents, and other pests. The facility did not have a standalone written pest control policy at the time of survey due to an administrative oversight. Although basic pest prevention practices were in place through housekeeping, maintenance, and outside services as needed, those practices had not been formalized into a written policy available upon request. To prevent recurrence, the facility added the policy to its policy and procedure manual and will maintain it as part of its required operational policies. The policy will be enforced through administrator oversight, staff reporting expectations, prompt response to pest concerns, and use of licensed pest control professionals when needed. Resident safety will remain the priority. Any treatment will be completed in a manner that limits resident exposure to chemicals, equipment, or restricted areas. The Administrator will provide the policy to staff and conduct training on 3/27/26. Staff will be educated on prevention measures, reporting expectations, documentation requirements, and resident safety during treatment. The policy will be maintained in the facility’s policy and procedure manual and made accessible upon request. Description of how the licensee will monitor the corrective actionThe Administrator or designee will monitor compliance through annual review of the policy manual to ensure the Environmental Pest Control Policy remains current, complete, and accessible upon request. Pest-related concerns and documentation will also be reviewed as needed to ensure the policy is being followed. If the policy is found to be missing, outdated, or not readily accessible, corrective action will be taken immediately, including updating or replacing the policy and re-educating staff as needed.

The Administrator is scheduled to correct the deficiency on 04/12/2023 and has added an annual reminder to her calendar to complete the TRAIN and update the EMResource. Monitoring for completion by reviewing documentation from CO TRAIN will be provided by the Director of Operations on an annual basis.

The Administrator purchased three fire-resistant wastebaskets on 04/06/2023. When a new resident who smokes is admitted or if a current resident starts smoking, the facility will make a notation to their chart and provide a fire-resistant wastebasket for their room. To monitor the issue the Administrator added checking the fire-resistant wastebaskets of residents who smoke to the monthly safety check as completed by maintenance. The Administrator added monitoring of the monthly safety checks to the facility's QAPI process on 02/08/2024. The Administrator will review the task every month for three months and will initial the safety check sheet to show compliance.