Haven of Cottonwood

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Aug 26, 2021

  Based on observations, clinical record review, resident and staff interviews, and facility policy, the facility failed to ensure one resident (#19) was adequately supervised during dining to prevent choking and burning accidents. As a result, the Conditions of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. The deficient practice could result in choking incidents and [CONDITION(S)]. Findings include: On August 25, 2021 at 10:50 am, the Condition of IJ was identified. The executive director (staff #15), Director of Nursing (DON/staff #30), and clinical resource nurse (staff #63) were informed of the facility's failure to adequately supervise a resident (#19) who had an order regarding strict aspiration precautions during dining. […]

• No harm, potential for more than minimal, widespreadF882Nov 17, 2022

  Based on staff interviews and facility policy, the facility failed to designate a qualified individual as the Infection Preventionist (IP) on an ongoing basis. The deficient practice could result in improper infection prevention practices in the facility. Findings include: An interview was conducted with the [NAME] President of Clinical Operations (staff/#68) and telephone interview with the Registered Nurse/Infection Preventionist (RN/IP/staff #9) on November 17, 2022 at 11:26 AM. The IP stated that she comes in once a month to do rounds and the last time she was in the facility was at the end of September 2022. It was then stated that the Director of Nursing (DON/staff #25) is overseeing the day to day infection control and education. They stated the DON is not certified. […]

• No harm, potential for more than minimal, patternF584May 21, 2025

  Based on observations, interviews, facility documentation and policy, the facility failed to ensure a clean, sanitary, and safe environment in the residents' shower rooms, and in shared resident bathroom on the 200-Hall. The deficient practice could result in the spread of infection and the failure to achieve a home-like environment. Findings include: A facility walkthrough was conducted with the Maintenance Supervisor (Staff #302) and the Maintenance Manager (Staff #31) on May 19, 2025 at 08:58 a.m. to observe a resident shared restroom on the 200-Hall. All parties observed feces stuck to the inside of the commode, feces on the handrail, feces on the floor, dust and calcification in the toilet bowl, and a used and stained urinal (occupants of both rooms were females). […]

• No harm, potential for more than minimal, patternF609May 21, 2025

  Based on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure an allegation of abuse was reported timely to required entities for one resident (#326). The deficient practice could lead to ongoing abuse leading to harm of a resident. -Findings include: Resident #326 was admitted to the facility on [DATE], with diagnoses that included hypotension, unsteadiness on feet, degeneration of nervous system due to alcohol, and unspecified dementia. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. […]

• No harm, potential for more than minimal, patternF610May 21, 2025

  Based on clinical records, review of facility documentation, review of the State Agency (SA) database, staff interviews and review of policy and procedure facility failed to ensure two allegations of abuse (resident #171& #326) and an allegation of neglect (resident #26) were fully investigated. The deficient practice could result in allegations of abuse and neglect not being investigated and abuse/neglect occurring in the facility. Findings include: Regarding Resident #26 -Resident #26 was admitted to the facility on [DATE] with diagnoses that included hypotension, chronic kidney disease, and nocturia. A report was received by the State Agency on January 4, 2023 regarding an allegation of neglect. However, the report did not identify the alleged perpetrator. […]