Monument Healthcare Cottonwood Creek

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 4, 2024

  Based on observation, interview, and record review the facility did not, for 2 of 26 sampled residents, ensure that the environment remained as free of accident hazards as possible, and that each resident received adequate supervision and assistance device to prevent accident. Resident identifiers: 35 and 56. Findings include: 1. Resident 56 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction due to thrombosis, type 2 diabetes mellitus, squamous cell carcinoma, protein-calorie malnutrition, atrial fibrillation, need for assistance with personal care, history of falling, mood disorder, pressure ulcer of sacral region, dementia, generalized edema, anemia, hypertension, hyperlipidemia, and renal osteodystrophy. […]

• Actual harm, isolatedF689May 5, 2022

  Based on observation, interview, and record review, it was determined, the facility did not ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 3 out of 26 sampled residents, residents that had multiple falls with injuries were not provided interventions or adequate supervision to prevent falls from occurring. A resident had a fall that resulted in a left [CONDITION(S)] and the resident was hospitalized . In addition, a resident had a fall resulting in a hematoma to the forehead. Resident identifiers: 32, 48, and 53. Findings included: 1. […]

• Actual harm, isolatedF692May 5, 2022

  Based on interview and record review, it was determined, the facility did not ensure that residents maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrated that this was not possible. Specifically, for 1 out of 26 sampled residents, a resident who had experienced a significant weight loss did not have interventions put in place to prevent further significant weight loss. Resident identifier: 53. Findings included: Resident 53 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 53's medical record was reviewed on 5/5/22. […]

• No harm, potential for more than minimal, patternF584Apr 4, 2024

  Based on observation and interview, it was determined that the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, soiled ceiling tiles and dusty air vents were observed throughout the facility, the west hall was found to have a urine-like odor, and the facility environment was in disrepair. Findings include: 1. On 4/1/24 at 9:49 AM and 4/2/24 at 10:56 AM, a strong smell of urine was observed throughout the west hall. The odor could not be pinpointed to a specific room or resident. On 4/2/24 at 12:03 PM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated she did notice a smell in the west hall and that the whole west hall had a smell. 2. […]

• No harm, potential for more than minimal, patternF609Apr 4, 2024

  Based on observation, interview, and record review, it was determined that for 6 of 26 sampled residents, that the facility did not ensure that all allegations of abuse or neglect were reported to the State Survey Agency (SSA). In addition, the facility did not ensure the results of all investigations of alleged abuse and neglect were reported to the necessary officials, including the SSA, within 5 working days. Due to the facility's identification of missed reporting of reportable allegations and their subsequent implementation of corrective measures, as well as the facility's current compliance in this regulatory area, this deficiency was determined to be past noncompliance. The facility achieved compliance on 3/15/2024. […]