Cottonwood Healthcare Center

In the surveyor’s words

From the most serious findings on record at Cottonwood Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF583Jul 30, 2025

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

• No harm, potential for more than minimal, widespreadF761Jul 30, 2025

  Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored in accordance with the facility's policies and procedures (P&P), and accepted professional principles for a census of 95 when:1. A total of 5 loose pills were found in medication cart 4;2. An opened Polymyxin B-tmp eye drop (an eye drop used to treat bacterial eye infections), an opened Incruse Ellipta inhaler (a medication used to treat airflow obstruction in adults), and an opened Symbicort inhaler (a medication used to treat breathing difficulty) had no opened date label; and,3. […]

• No harm, potential for more than minimal, widespreadF761Jul 15, 2021

  Based on observation, interview, and record review, the facility failed to ensure that all drugs were labeled and disposed of in accordance with professional standards when 2 of 4 medication carts had expired medications, unlabeled medications, inappropriate handling of hazardous drugs, unrefrigerated medications, personal resident belongings and 1 controlled medication destruction container not disposed of for a census of 80 when: 1. Four unopened insulins (lowers sugar) (1 vial and 3 pens) were labeled Refrigerate; 2. One [MEDICATION(S)] Cream (relieves muscle pain) 0.025% was not labeled; 3. Four loose pills, (1 small round pink with #5 inscribed; 2 small white pills (G +32?; ZG40?); and a small blue pill [F 5]) were underneath residents medication packs; 4. […]

• No harm, potential for more than minimal, patternF628Jul 24, 2026

  Based on observation, interview, and record review, the facility failed to provide a notice of transfer to 51 long-term care residents and/or their representatives at least 30 days before transfer, when 51 residents were transferred to other facilities within 10 days of transfer notification. This failure decreased the facility's potential to provide safe and effective transition of care while maintaining the residents' highest practicable physical, mental and psychosocial wellbeing.Findings: A review of the admission records for 51 long-term care residents indicated the following:- Resident 1 was readmitted to the facility in March 2025 and transferred to another facility on 7/17/26;- Resident 2 was readmitted to the facility in July 2025 and transferred to another facility on 7/16/26;-… […]

• No harm, potential for more than minimal, patternF801Jul 9, 2026

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