Cottonwood Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF692Jul 12, 2023

  Based on observations, record review and interviews, the facility failed to implement appropriate nutritional interventions for one (#1) of three residents reviewed for nutrition out of 20 sample residents to maintain acceptable parameters of nutritional status. Resident #1 had diagnoses of Parkinson's disease, protein calorie malnutrition, dysphagia (swallowing difficulty) and dementia, which made her at nutritional risk. She required supervision assistance at meals, which through observations was not provided. The facility failed to implement nutrition interventions when the resident sustained a severe weight loss. Due to the facility's failures, Resident #1 sustained a weight loss of 15.1% (16.8 lbs) from 2/9/23 through 7/6/23, which was considered severe. Findings include: I. […]

• Actual harm, isolatedF758Jul 12, 2023

  Based on observation, records review and interviews, the facility failed to adequately monitor the resident for unnecessary psychotropic medications needed to provide effective and person-centered care for three (#15, #89 and #26) of five residents reviewed for use of psychotropic medication out of 18 sample residents. Record review revealed that Resident #15 had exit-seeking behaviors. The facility failed to obtain consent prior to increasing the administration of antipsychotic medication (Seroquel) and failed to ensure the antipsychotic medication administered was given to treat the resident's medical symptoms and not used for discipline or convenience. […]

• Actual harm, isolatedF692Apr 7, 2022

  Based on observations, record review and staff interviews, the facility failed to ensure two (#8 and #12) of four residents observed for nutrition/hydration maintained acceptable parameters of nutritional status to avoid unintended weight loss out of 20 sample residents. The facility failed to identify and consistently implement timely interventions to maintain residents' weight. The facility failed to timely address Resident #8's significant weight loss and poor intake. Resident #8 lost 17.4 pounds (lbs) between 2/3/22 and 4/3/22, resulting in 11.24% total weight loss in two months. The facility did not identify the weight loss between 2/3/22 and 3/15/22 at 7.11% as a significant loss, delaying interventions to potentially slow the weight loss decline of Resident #8. […]

• Actual harm, isolatedF689Mar 11, 2021

  Based on record review and interviews the facility failed to ensure residents were as free from accident hazards as possible for one (#1) of three residents reviewed for falls out of four sample residents. Resident #1, a known fall risk, sustained five falls during the course of his stay in the facility (8/26/2020; twice, 10/23/2020, 10/26/2020 and 1/27/21). On 10/26/2020 he was found lying on the floor next to his bed. He was assessed prior to moving and upon getting him up he verbalized pain in his back. On 10/27/2020 he was sent out to an acute care facility to be evaluated as to the cause of continued verbalization of pain. The resident had a spinal X-ray and was found to have a compression fracture to his L2 (lumbar spine) and was sent back to the facility with a back brace. […]

• No harm, potential for more than minimal, widespreadF882Nov 21, 2024

  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. […]