Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Haven Of Cottonwood during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
Surveyors observed unsanitary conditions in shared resident restrooms and shower rooms, including feces on surfaces, dust, calcification, and a used urinal. An unlabeled chemical was found within resident reach, and vents and drains were unclean. A resident reported ongoing issues with restroom cleanliness and lack of staff response. The facility lacked an official housekeeping manager, and cleaning responsibilities were not adequately fulfilled according to policy.
The facility did not ensure that an RN was present for at least eight consecutive hours each day, as required. On several occasions, there was no RN coverage, and when an RN was unavailable, the DON or LPNs would cover shifts, which did not meet regulatory standards. Staff interviews confirmed awareness of the requirement and acknowledged that the facility's RN coverage was insufficient, particularly on weekends.
Surveyors found that the facility did not maintain accurate reconciliation and documentation of controlled substances, with missed and duplicate staff signatures, count inconsistencies, and incorrect dates in the narcotic logbook. Interviews with the DON, clinical resource staff, and an RN confirmed that these practices did not meet facility expectations for shift-to-shift narcotic counts.
Surveyors observed multiple failures in food safety and hygiene, including expired and improperly stored food, lack of hand hygiene by staff, and unsanitary kitchen equipment and surfaces. Staff interviews confirmed inconsistent cleaning practices and lack of oversight, with facility policies not being consistently followed.
A CNA failed to perform hand hygiene before and after obtaining a resident's vital signs and did not disinfect equipment as required. The CNA then entered another resident's room without sanitizing hands. Interviews with staff and review of facility policy confirmed that hand hygiene and device disinfection are expected before and after resident care to prevent infection transmission.
A resident with moderate cognitive impairment was subjected to inappropriate language by a nurse after a startling interaction. Although the incident was documented and the resident did not report feeling mistreated, the facility did not report the allegation of verbal abuse to the required authorities within the timeframe specified by policy, resulting in a deficiency related to timely reporting of suspected abuse.
The facility did not conduct comprehensive investigations into allegations of abuse and neglect involving three residents, including cases of verbal abuse by a staff member and a family member, and an allegation of neglect. Investigation reports lacked required interviews, witness statements, and documentation, failing to meet the facility's own policy standards.
A resident with multiple medical and mental health diagnoses did not have their participation in activities properly assessed or documented, despite having an activities care plan in place. The Activities Manager was unaware of the need for individual documentation and relied on memory to complete records, while the facility's system only tracked group attendance. Leadership confirmed that individual tracking was expected, and the resident was not informed about available activities, with no activity calendar present in their room.
Two residents with cognitive impairment and mobility issues were not adequately supervised or assessed, leading to one resident eloping from the facility on multiple occasions and another experiencing repeated falls without timely care plan updates or consistent neuro checks. Staff interviews and record reviews revealed missing assessments, incomplete documentation, and a lack of appropriate interventions, in violation of facility policies.
A resident with cognitive impairment and multiple diagnoses was administered Bupropion, a psychotropic medication, for several days before informed consent was obtained. The resident's representative later declined consent, and staff interviews confirmed that facility policy requires psychotropic consent prior to administration, which was not followed in this instance.
A resident with hepatic encephalopathy and alcoholic cirrhosis received Morphine Sulfate for pain levels below the prescribed threshold, as documented on the MAR. Both nursing staff and the DON confirmed that the medication was given outside the ordered pain scale, in violation of facility policy and prescriber instructions.
A resident with moderate cognitive impairment received Bupropion HCL ER for anxiety without documented informed consent from their representative. The medication was administered for three days before the representative declined consent, and facility staff confirmed that this was not in accordance with policy requiring consent for psychotropic use.
Surveyors found that two medication carts contained improperly stored and labeled medications, including unrefrigerated Lorazepam, bottles with crusted residue, missing open dates, and medications not in original containers. Staff interviews confirmed these practices were against facility policy, and both staff and residents expected medications to be stored and prepared in a clean, safe manner.
A resident with moderate cognitive impairment and multiple medical conditions was spoken to disrespectfully by a staff member, who told the resident to "please settle down and stop acting like a a**" after being startled during an interaction. Staff interviews and policy review confirmed that this language was inappropriate and not in accordance with professional conduct or resident rights standards.
The facility did not follow its policies for investigating abuse and neglect allegations, failing to conduct thorough investigations or adequately protect two residents from further harm. In both cases, required interviews and documentation were incomplete or missing, and actions to separate alleged perpetrators from residents were not consistently documented. Staff interviews confirmed awareness of policy requirements, but the necessary steps were not followed in these incidents.
A resident with multiple medical and psychiatric diagnoses was transferred to the hospital for COVID-19-related symptoms and remained hospitalized for an extended period. The facility failed to document or provide required notification to the resident's public fiduciary regarding the transfer and hospital admission, despite policy and staff statements indicating this is standard procedure. The deficiency was identified through record review, staff interviews, and a complaint from the responsible party.
A resident with documented cognitive impairment and a history of being unable to make decisions was admitted with multiple diagnoses, including severe protein-calorie deficit. Despite clear evidence of cognitive issues from hospital records and facility staff observations, the MDS admission assessment was incomplete, lacking both a BIMS score and staff assessment for mental status. Staff interviews confirmed the resident's confusion and wandering behavior, but required cognitive assessments were not performed as outlined in facility policy and the RAI manual.
A resident with cognitive impairment and communication deficits was admitted with multiple complex diagnoses. Despite documentation of cognitive issues and a history of confusion, the care plan only addressed communication challenges related to jaw carcinoma and did not include interventions for cognitive impairment. The omission was evident when the resident was found outside the facility on two occasions after becoming confused, and staff interviews confirmed the lack of appropriate care planning for cognitive deficits.
A resident with multiple diagnoses and a history of falls experienced repeated falls and behavioral changes over several weeks. Despite ongoing incidents and interventions such as 1:1 supervision and environmental modifications, the care plan was not updated to reflect these changes. Staff interviews and record review confirmed that the care plan was not revised as required after each fall or significant change in condition.
A resident with multiple complex diagnoses experienced several falls and changes in condition, but the facility failed to maintain complete and accurate medical records. Documentation was missing for neuro checks, progress notes, and notifications to the provider and family after several incidents, despite facility policy and staff interviews confirming these actions were required.
A resident with multiple medical conditions experienced a fall resulting in right arm discomfort and limited mobility. Although a provider ordered a right arm x-ray to rule out fracture, the x-ray was never completed due to a documentation error by nursing staff. The order was not followed, and the omission was only discovered later during a review of the clinical record and staff interviews.
A resident with complex medical and mental health needs exhibited significant behavioral changes after readmission. Although a psychiatric consultation was ordered and a telehealth visit occurred, the psychiatric provider's notes were not present in the medical record at the time of review. Staff confirmed the visit took place and that records were requested, but the absence of timely documentation resulted in an incomplete medical record, contrary to facility policy and federal requirements.
A resident with significant medical needs and a physician order for weekly weight monitoring did not have weights taken or documented as required. Only a single weight, entered by a dietary consultant using prior hospital data, was found in the record. Staff interviews confirmed that the expected process for obtaining and recording weights was not followed, and there was no documentation of refusal by the resident.
Two residents in the facility did not receive wound care as ordered by their physicians, leading to a deficiency in care. One resident, who was cognitively intact, had her wound care neglected, with the last bandage change noted several days past the scheduled time. Another resident with osteomyelitis and cellulitis had a blood-soaked bandage that was overdue for changing. Staff admitted to signing off on care that was not provided, violating the facility's documentation policy and potentially risking wound infections.
The facility failed to provide adequate nail care and shower assistance to two residents, leading to concerns about poor hygiene and potential infection. A resident with chronic conditions was observed with long, dirty fingernails, and received only one shower per week, contrary to the facility's policy. Staff interviews revealed inconsistencies in documentation and monitoring, with missing shower sheet forms and lapses in record-keeping.
The facility failed to implement enhanced barrier precautions for two residents with indwelling catheters, as staff did not wear gowns during high-contact care activities. Despite following hand hygiene and glove protocols, the lack of gown use during catheter care was observed. Interviews revealed that staff had not been trained on the new EBP guidelines, which require gowns and gloves for high-contact activities, regardless of MDRO status.
A facility failed to obtain a physician order for an indwelling catheter for a resident admitted with acute cystitis and acute kidney failure. Despite the care plan indicating the catheter's use for bladder outlet obstruction, no physician order was documented from admission until several days later. Observations and staff interviews confirmed the catheter's presence without an order, contrary to facility policy requiring documentation of clinical indications and ongoing assessment.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Maintain Clean and Sanitary Resident Restrooms and Shower Rooms
Penalty
Summary
The facility failed to maintain a clean, sanitary, and safe environment in the residents' shower rooms and a shared bathroom on the 200-Hall. During a walkthrough with the Maintenance Supervisor and Maintenance Manager, surveyors observed feces on the inside of the commode, on the handrail, and on the floor, as well as dust and calcification in the toilet bowl and a used, stained urinal in a shared restroom used by female residents. In the 200-Hall shower room, an unlabeled blue chemical was found within reach of residents, and the shower drains contained soap scum and hair. The shower room vent was covered in a thick layer of black and grayish substance. These conditions were directly observed by staff and surveyors. A resident expressed dissatisfaction with the cleanliness of the shared restroom, stating that feces were present on the floor and that staff had been alerted but took no action to resolve the issue. Interviews with the Maintenance Supervisor and Maintenance Manager revealed that there was no official housekeeping manager at the time, and the maintenance manager was covering the position. Facility documentation and policies indicated that maintaining a clean and safe environment is the responsibility of the Environmental Services Manager and Housekeeper, and that cleaning and disinfection should occur regularly and when surfaces are visibly soiled.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. Review of facility documentation, including the facility assessment and RN punch detail records, revealed multiple dates where there was no evidence of RN coverage for the required period. The facility assessment indicated that staffing should include at least one RN per 24-hour period, with assignments based on patient care needs. However, on specific dates, there was no RN coverage documented, and the staffing coordinator confirmed that RN coverage was not consistently met. When an RN was unavailable, the Director of Nursing (DON) would occasionally cover the RN floor nurse role, and at other times, LPNs or the staffing coordinator would fill in, despite being aware that this did not meet the facility's expectations or regulatory requirements. Interviews with the staffing coordinator and DON confirmed awareness of the requirement for RN coverage and acknowledged that the facility did not always meet this standard. The clinical resource staff also noted that the facility had lower RN hours, particularly on weekends, compared to competitors, and that this issue would be addressed in future quality performance discussions. The census during the review period ranged from 38 to 67 residents, with a sample of 20 residents reviewed. The lack of consistent RN coverage could result in residents not receiving advanced care activities to meet their needs, as stated in the report.
Failure to Ensure Accurate Narcotic Reconciliation and Documentation
Penalty
Summary
The facility failed to maintain proper safeguards and systems for the accurate reconciliation and accounting of controlled substances. During an observation of Medication Cart #1's narcotic logbook, surveyors identified several discrepancies in the Shift to Shift Narcotic Sheet & Card Verification for a period in May. These included count inconsistencies over multiple days, six missed staff signature entries, duplicate signature entries, and an incorrect year written on the log sheet. Interviews with the DON, clinical resource staff, and an RN confirmed that the facility's expectation is for two licensed nurses to sign off on narcotic counts at each shift change, and that the missing or duplicate signatures did not meet facility standards. Facility policy requires the DON to supervise all personnel administering medications and mandates that medication-related issues be reviewed as part of the quality assurance and performance improvement process. Despite these policies, the observed documentation failures and inconsistencies in narcotic counts indicate that the required procedures were not consistently followed, leading to a deficiency in the facility's pharmaceutical services.
Deficient Food Safety, Storage, and Hygiene Practices in Kitchen
Penalty
Summary
The facility failed to maintain proper food safety, storage, and hygiene practices in the kitchen, as evidenced by multiple observations of expired, improperly sealed, and undated food items. During a kitchen inspection, surveyors found cooked bacon wrapped in tinfoil without date labeling, strawberries with visible mold, and bags of lettuce and green onions that were either unsealed, undated, or past their use-by dates. Additionally, a staff member was observed discarding and then retrieving bacon from the trash, then handling food without washing hands or wearing gloves, and failing to perform hand hygiene between tasks. Further inspection revealed that kitchen equipment and surfaces were not maintained in a sanitary condition. The interior and exterior of the ice machine had visible dirt and dust buildup, and the large mixer and gas range were found with food splatter, grease, and dust. Cleaning logs indicated that some equipment, such as refrigerators and the ice machine, had not been cleaned for several weeks. Ceilings, vents, and lights in the kitchen and freezer room were also covered in dust, dirt, and cobwebs, with no documented cleaning schedule for these areas. Interviews with staff, including the cook, dietary aide, maintenance manager, DON, dietary manager, and executive director, confirmed inconsistent cleaning responsibilities and a lack of supervisory oversight or documentation for food checks and cleaning tasks. Facility policies required proper food storage, dating, and regular cleaning of equipment, but these were not consistently followed. The facility was unable to provide a policy for cleaning kitchen ceilings and lights, further contributing to the deficiency.
Failure to Follow Hand Hygiene and Infection Control Practices During Resident Care
Penalty
Summary
A Certified Nursing Assistant (CNA) was observed failing to perform hand hygiene before and after obtaining a resident's vital signs near the nursing station. The CNA did not sanitize or wash his hands prior to or after providing care, and after recording the vital signs, proceeded to enter another resident's room without sanitizing his hands. The CNA acknowledged during an interview that he did not follow the facility's hand hygiene expectations, which require handwashing before and after resident contact and when obtaining vital signs, as well as disinfecting the equipment used. Another CNA confirmed the facility's expectations for hand hygiene and device disinfection when providing care or obtaining labs. The Director of Nursing/Infection Preventionist (DON/IP) and a Clinical Resource staff member reiterated that hand hygiene is required before and after all patient care activities, including obtaining vital signs, and that equipment disinfection is equally important. The facility's infection control policy also outlines specific situations requiring hand hygiene, emphasizing its role in preventing the spread of infection.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of verbal abuse involving a resident with moderate cognitive impairment and multiple medical diagnoses, including dementia and nervous system degeneration. On the evening of November 8, 2021, a registered nurse used inappropriate language toward the resident after being startled by the resident's actions. The incident was documented in a health status note, and the resident did not express offense or dissatisfaction with care during subsequent interviews. However, the facility did not report the allegation to the required authorities until November 16, 2021, several days after the incident occurred. Interviews with facility staff confirmed that the policy requires immediate reporting of suspected abuse, with some staff specifying a two-hour timeframe for such reports. The facility's abuse policy outlines the need for prompt reporting and investigation to protect residents. Despite these policies, the delay in reporting the incident to the appropriate entities constituted a failure to follow established procedures for handling allegations of abuse.
Failure to Conduct Thorough Investigations of Abuse and Neglect Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse and neglect involving three residents. For one resident with hypotension, chronic kidney disease, and nocturia, an allegation of neglect was reported to the State Agency, but the facility did not submit a comprehensive investigation. The 5-day investigation report lacked interviews with residents and staff, did not include witness statements, and failed to specify when interviews were conducted or identify witnesses. In another case, a resident with monoplegia, chronic heart failure, and depression experienced a family-to-resident verbal abuse incident. The clinical record documented the resident's depression and suicidal ideation but did not reference the incident with the family member or indicate any monitoring or visitation restrictions. The facility's investigation report was undated, did not include interviews with witnesses, the alleged perpetrator, or staff, and lacked witness statements and interview details. A third incident involved a resident with hypotension, unsteadiness, nervous system degeneration, and dementia, who was verbally abused by a staff member. The facility reported the incident but the investigation report did not include witness statements or interviews with other residents to determine if there was a trend. The staff member involved was suspended and educated, but the investigation did not meet the facility's policy requirements for thoroughness, as outlined in their abuse policy.
Failure to Assess and Document Resident Activity Participation
Penalty
Summary
The facility failed to properly assess and monitor the activities program for one resident with multiple diagnoses, including chronic obstructive pulmonary disease, above-knee amputation, depression, and anxiety disorder. The resident was cognitively intact and had an activities care plan that included providing leisure supplies, introducing the resident to others with similar interests, modifying schedules as needed, offering a variety of activities, and reassessing preferences. However, documentation of the resident's participation in activities was lacking, with task sheets for various activities showing no entries for the past thirty days, and activity tracking only indicating limited participation in movies/TV and occasional group activities. Interviews with the Activities Manager revealed that she was unaware of the requirement to document each resident's participation in activities and that the documentation system had only recently become operational. The Activities Manager admitted to not having documentation for any residents and relied on memory to complete activity records retroactively. The activities list provided only showed aggregate attendance numbers without identifying individual residents, making it impossible to monitor or evaluate specific residents' engagement or changes in participation. Further interviews with facility leadership confirmed that there was an expectation for the Activities Manager to track and review individual resident participation in activities, as this information is necessary to identify trends or concerns such as depression. The resident in question expressed interest in attending group activities depending on the type but was unaware of the current activity offerings, and no activity calendar was present in the resident's room. The facility's policy required monitoring and evaluating residents' responses to activities and revising approaches as appropriate, which was not followed in this case.
Failure to Prevent Elopement and Repeated Falls Due to Inadequate Supervision and Assessment
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for two residents, resulting in deficiencies related to elopement and repeated falls. One resident with a history of cognitive impairment, communication deficits, and a public fiduciary was admitted without a completed cognitive assessment or care plan addressing his impaired cognition. Despite documentation from hospital records and therapy evaluations indicating cognitive impairment and the need for a guardian, the facility did not initiate interventions to mitigate risks associated with his condition. The resident was found ambulating alone on the street on two separate occasions, with staff only implementing a wander guard and behavioral care plan after these incidents. There was no evidence of a timely wandering risk evaluation, supervision/monitoring logs, or an investigation file for the elopement events, contrary to facility policy requirements. Another resident, re-admitted with diagnoses including Parkinson's disease, traumatic brain injury, dementia, and abnormal gait, experienced multiple falls shortly after admission. The resident's care plan was not updated with new interventions for an extended period despite repeated falls, and there was no evidence of neuro check logs during the admission period. Documentation revealed the resident was highly confused, unable to use the call light, and required frequent monitoring and 1:1 supervision at times, but the facility did not consistently implement or document these interventions. Staff interviews confirmed that care plan updates and supervision were lacking during a period of repeated falls, and that the facility did not employ 1:1 supervision due to staffing limitations, even when it was indicated as necessary. Facility policies required prompt assessment, documentation, and investigation of accidents and incidents, as well as individualized fall prevention plans and immediate safety strategies for residents with cognitive or behavioral risks. However, the facility did not follow these protocols for the residents in question, as evidenced by missing assessments, incomplete care plans, lack of documentation, and failure to implement or document appropriate interventions after repeated incidents. These actions and omissions resulted in residents being exposed to preventable accidents and inadequate supervision.
Psychotropic Medication Administered Without Prior Consent
Penalty
Summary
A resident with diagnoses including atrial fibrillation, dementia with mood disturbance, anxiety, muscle weakness, and cognitive communication deficit was admitted to the facility. The resident had impaired cognition as indicated by a BIMS score of 10 and no recent depressive symptoms per the Resident Mood Interview. The care plan included administration of antidepressant medication for depression. An order for Bupropion HCL Extended Release for anxiety was initiated, and the medication was administered to the resident over a three-day period. However, the required informed consent for the psychotropic medication was not obtained prior to administration. The resident's representative declined consent for Bupropion after the medication had already been given. Interviews with facility staff, including an LPN, the clinical resource, and the DON, confirmed that facility policy mandates obtaining psychotropic medication consent before administration, and this expectation was not met in this case. Facility policies also state that residents have the right to be informed and to decline treatment with psychotropic medications.
Pain Medication Administered Outside of Prescribed Parameters
Penalty
Summary
Staff failed to administer pain medication according to the prescribed parameters for a resident with hepatic encephalopathy and alcoholic cirrhosis of the liver with ascites. The physician's order specified Morphine Sulfate 5 mg by mouth every 3 hours as needed for pain levels between 7 and 10. However, documentation on the medication administration record (MAR) showed that the medication was given three times for pain levels of 6, 3, and 6, which were outside the ordered pain scale parameters. Interviews with the registered nurse and the Director of Nursing confirmed that the medication was administered outside of the specified pain scale, contrary to facility policy and prescriber orders. Both staff members acknowledged that PRN pain medication orders require adherence to dosage, frequency, and pain scale, and that the MAR should reflect the pain level and effectiveness of the medication. The facility's policy requires medications to be administered in accordance with prescriber orders, including any required time frame.
Psychotropic Medication Administered Without Consent
Penalty
Summary
A resident with diagnoses including atrial fibrillation, dementia with mood disturbance, anxiety, muscle weakness, and cognitive communication deficit was admitted to the facility. The resident had a BIMS score indicating moderate cognitive impairment. An order for Bupropion HCL Extended Release was written for anxiety, and the medication was administered to the resident over three days. The clinical record did not show that consent was obtained from the resident or their representative prior to starting the medication. On the third day of administration, the resident's representative declined informed consent for the psychotropic medication, after which the medication was discontinued. Interviews with the resident's representative, an RN, the Clinical Resource, and the DON confirmed that the medication was given without proper consent, which was against the family's wishes and contrary to facility policy. The facility's policy stated that residents have the right to decline treatment with psychotropic medications.
Improper Medication Storage and Labeling in Medication Carts
Penalty
Summary
Surveyors observed that two of four medication carts contained medications that were not stored according to professional standards and facility policy. Specifically, an unrefrigerated vial of Lorazepam labeled to be kept refrigerated was found in the narcotic storage area, and several medication bottles, including Geri-Tussin, Milk of Magnesia, Wild Cherry Pro-Stat, Geri-Lanta, and Pepto Bismol Ultra, were found with crusted residue, missing labels, or missing open dates. Additionally, a medicine cup containing two Zofran tablets was found in a cart drawer, not in its original container. These findings were confirmed during interviews with the DON and staff, who acknowledged that these practices were against facility policy and expectations. Further interviews with staff and residents indicated an expectation that medications are prepared and stored in a clean and safe environment. The facility's own policy requires medications to be stored in their original containers, with proper labeling and dating, and for medication storage areas to be kept clean and sanitary. The observed deficiencies demonstrated a failure to adhere to these standards, as evidenced by improper storage, lack of labeling, and unsanitary conditions in the medication carts.
Failure to Treat Resident with Respect and Dignity
Penalty
Summary
A resident with diagnoses including hypotension, unsteadiness, nervous system degeneration due to alcohol, and unspecified dementia was involved in an incident where a staff member used disrespectful language. During an interaction, the resident, who had a moderate cognitive impairment as indicated by a BIMS score of 12, expressed frustration and raised his hand at a nurse. The nurse, startled by the resident's actions, responded by telling the resident to "please settle down and stop acting like a a**." This exchange was documented in the resident's health status note and was later reported as a facility event. Interviews with staff and review of facility policies confirmed that such language is considered inappropriate and not in line with the expected standards of professional conduct or resident rights, which require all residents to be treated with kindness, respect, and dignity. The incident was acknowledged by the staff member involved, and other staff interviewed agreed that the language used was disrespectful and not acceptable according to facility policy.
Failure to Implement Abuse and Neglect Investigation Policies
Penalty
Summary
The facility failed to implement its policy regarding the thorough investigation of abuse and neglect allegations and did not adequately protect residents from further abuse in two separate cases. In the first case, a resident with hypotension, chronic kidney disease, and nocturia was the subject of a neglect allegation involving a CNA who reportedly told the resident not to use the call light for at least an hour. The facility's self-report lacked details about the incident and the alleged perpetrator, and there was no documentation in the clinical record regarding the incident, assessment, or required notifications. The subsequent investigation did not include interviews with other residents or staff, lacked witness statements, and failed to specify when interviews were conducted or who the witnesses were. The investigation concluded no neglect occurred, but the CNA involved had a documented history of poor performance and was later terminated for a separate incident. In the second case, a resident with monoplegia, chronic heart failure, and depression was involved in an incident of alleged verbal abuse by a family member. The facility's self-report did not indicate whether the family member was separated from the resident during the investigation. While progress notes showed the resident was separated from the spouse and the incident was reported to the physician, administrator, and DON, there was no documentation of follow-up regarding the resident's interaction with the spouse or any limitations on visitation. The investigation report did not include interviews with the alleged perpetrator or potential witnesses, and summaries of interviews lacked details about timing and witness identity. Staff interviews revealed an understanding of the importance of following policies to ensure resident safety and thorough investigations, but staff were unfamiliar with the specific incidents. The facility's policy required immediate suspension of alleged employee perpetrators and interviews with a minimum of three residents to identify trends, but these steps were not consistently documented or followed in the cases reviewed.
Failure to Notify Responsible Party of Resident Transfer and Hospital Admission
Penalty
Summary
A deficiency occurred when the facility failed to ensure that all required notifications regarding a resident's transfer and discharge were made. The resident in question had multiple diagnoses, including hyperlipidemia, bipolar disorder, anxiety disorder, and gastro-esophageal reflux disease, and had a public fiduciary listed as the responsible party, guardian, and emergency contact. Documentation reviewed showed that while a discharge assessment indicated the responsible party was notified, it did not specify who was notified or when. There was no documentation in the order summary report or progress notes indicating that the responsible party was informed of the resident's transfer to the hospital or subsequent admission. Further review revealed that the resident was transferred to the emergency room due to COVID-19 symptoms and low oxygen saturation, and was admitted to the hospital for a prolonged stay. The resident did not return to the facility until over two weeks later. During this period, there was no evidence in the medical record that the public fiduciary was notified of the transfer or hospital admission. A complaint was submitted to the State Agency by the responsible party, stating that they were not informed of the resident's transfer until a care conference, and that the facility did not accurately communicate the resident's status. Interviews with facility staff, including a CNA, LPN, and the DON, confirmed that the standard practice is to notify the responsible party or public fiduciary prior to a resident's transfer and to document this notification in the medical record. The staff acknowledged the importance of this communication and indicated that failure to notify is inappropriate. Facility policy also requires documentation of notification to the resident and/or legal representative when a transfer or discharge occurs, including in emergency situations. However, in this case, the required notifications and documentation were not completed.
Failure to Complete Comprehensive MDS Assessment for Cognitively Impaired Resident
Penalty
Summary
The facility failed to accurately complete a comprehensive Minimum Data Set (MDS) assessment within the required timeframe for a resident who was admitted with significant cognitive impairment and a history of being unable to make his own decisions. Hospital records prior to admission documented the resident's incompetence and need for a public fiduciary, as well as a history of cognitive impairment. Upon admission, the resident was noted to have diagnoses including malignant neoplasm of the mandible, temporomandibular joint disorder, and severe protein-calorie deficit. Facility documentation, including a speech therapy evaluation and progress notes, further confirmed the resident's cognitive impairment and poor ability to provide his own history. Despite this, the MDS admission assessment did not include a Brief Interview for Mental Status (BIMS) score, and both the cognitive patterns section and the staff assessment for mental status were left blank. Interviews with facility staff, including a CNA, LPN, and the DON, confirmed that the resident exhibited confusion and had episodes of wandering, with one incident involving the resident leaving the facility and being found a mile away. Facility policy and the RAI manual require comprehensive assessment of cognition and behavior to identify care needs and risks, but these were not completed as required for this resident.
Failure to Address Cognitive Impairment in Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan addressing a resident's cognitive communication deficit. The resident was admitted with multiple diagnoses, including malignant neoplasm of the mandible, temporomandibular joint disorder, and severe protein-calorie deficit. Hospital records and a speech therapy evaluation documented the resident's cognitive impairment and the presence of a guardian or public fiduciary. Progress notes and the Minimum Data Set (MDS) assessment further indicated cognitive and communication difficulties, but the MDS lacked a Brief Interview for Mental Status (BIMS) score and omitted staff assessment for mental status. Although a communication care plan was initiated, it only addressed the resident's jaw carcinoma and related communication challenges, without incorporating interventions for the cognitive impairment. There was no evidence in the care plan or clinical record that the resident's cognitive deficits were specifically addressed or that interventions were implemented to mitigate associated risks. This omission was contrary to facility policy, which requires comprehensive, person-centered care plans with measurable objectives and timetables based on ongoing assessments. The lack of appropriate care planning for cognitive impairment was highlighted by two incidents where the resident was found outside the facility, having become confused and lost while ambulating. Staff interviews confirmed the importance of care planning for known deficits and the potential for negative outcomes when such plans are not in place. Facility policies also emphasized the need for behavioral assessment and immediate safety strategies for residents with impaired cognition, which were not reflected in the resident's care plan.
Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was reviewed and revised in response to ongoing falls and changes in condition. The resident, who was re-admitted with multiple complex diagnoses including Parkinson's disease, dementia, traumatic brain injury, and a history of falls, experienced repeated falls and behavioral issues over a period of several weeks. Despite multiple documented incidents of falls, changes in mental status, and recommendations for increased supervision and interventions, the care plan was not updated to reflect these events between February 9 and March 4. Documentation shows that the resident was highly confused, unable to use the call light, and exhibited behaviors such as wandering, attempting to self-transfer, and removing medical devices. The resident had several falls, some resulting in injury or requiring hospital evaluation, and staff implemented various interventions such as 1:1 supervision, use of a wander guard, and environmental modifications. However, these interventions and the resident's changing needs were not consistently reflected in the care plan during the identified period. Interviews with staff confirmed that the expectation was to update the care plan after each fall or significant change, and the Director of Nursing acknowledged that the care plan lacked necessary updates during the period of repeated falls. Review of facility policy also indicated that care plans should be revised as residents' conditions change, but this was not done for the resident in question, resulting in a deficiency related to care planning and resident safety.
Incomplete and Inaccurate Medical Record Documentation After Multiple Falls
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete and accurate, as required by accepted professional standards. The resident, who had a history of Parkinson's disease, traumatic brain injury, dementia, abnormal gait, cognitive communication deficit, anxiety disorder, and required assistance with personal care, experienced multiple falls and changes in condition during their admission. Despite these incidents, there were significant gaps in the documentation, including missing neuro check logs, incomplete progress notes, and lack of evidence that notifications to the medical provider and family were made after several falls and changes in condition. Specific events included the resident being found on the floor multiple times, attempting to ambulate without assistance, and exhibiting confusion and forgetfulness. On several occasions, the resident was observed to have fallen or attempted to get out of bed or a wheelchair, sometimes resulting in injuries such as a skin tear or the removal of a Foley catheter with the balloon still inflated. Despite these incidents, the medical record often lacked documentation of assessments, neuro checks, and notifications to the provider and family, as required by facility policy and standard practice. Interviews with nursing staff and the Director of Nursing confirmed that the expected protocol after a fall includes assessment, documentation in the medical record, completion of an incident report, and notification of the provider and family. Review of the facility's documentation policy further emphasized the need for complete and accurate records, including details of care provided, assessments, and notifications. However, the review of the resident's clinical record revealed multiple instances where these requirements were not met, leading to incomplete and inaccurate documentation of the resident's care and condition.
Failure to Complete Ordered Post-Fall X-ray Assessment
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards by not following a physician's order for an x-ray assessment after a resident experienced a fall. The resident, who had a history of pneumonia, end-stage renal disease, acute pulmonary edema, hemiplegia, hemiparesis, and dysarthria, was noted to have rolled out of bed, resulting in discomfort and difficulty moving his right arm. A physician was notified and ordered an x-ray of the right arm to rule out a fracture. However, there was no evidence in the clinical record that the x-ray was completed, and documentation in the electronic medication administration record did not indicate that the x-ray was performed. Interviews with facility staff revealed that the process for obtaining an x-ray involved sending the order to a mobile x-ray company and scheduling the procedure. A nurse acknowledged that the x-ray was not completed and attributed the oversight to a documentation error, noting that once an order is charted on, it disappears from the system. The Director of Nursing confirmed that the x-ray was not done and that the issue was related to documentation by the floor nurse. Facility policy requires that a current list of orders be maintained in the clinical record and that all medication administration be documented immediately after administration.
Incomplete Medical Record for Resident Following Psychiatric Consultation
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete, accurate, and readily accessible, as required by federal regulations and facility policy. The resident in question had a complex medical history, including surgical aftercare, urinary tract infection, functional quadriplegia, and multiple mental health diagnoses. Upon readmission, the resident exhibited significant behavioral and cognitive changes, including self-transferring, unusual behaviors with personal and facility items, and emotional distress. The care plan included a referral to a mental health professional for trauma assessment and treatment. Despite documentation indicating that a psychiatric consultation was ordered and a telehealth appointment was conducted, there was no evidence in the clinical record that the psychiatric provider was consulted, evaluated the resident, or made any recommendations. Progress notes from staff confirmed that the telehealth visit occurred and that multiple attempts were made to obtain the visit notes from the contracted psychiatric provider. However, the psychiatric consultation records were not present in the resident's medical record at the time of review. Interviews with staff, including the CNA responsible for scheduling appointments, the Medical Records Manager, and the DON, confirmed that the psychiatric visit notes had not been received or uploaded into the electronic medical record in a timely manner. The facility did not have a policy specifying a required timeframe for uploading consult and visit notes. The absence of these records meant that the medical record was incomplete and did not fully document the services provided or the resident's response to care, as required by facility policy and federal regulation.
Failure to Monitor Resident Weight per Physician Orders
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including hemiplegia, dysphagia, acute respiratory failure, and malnutrition risk, did not receive weight monitoring as ordered by the physician. The care plan and physician orders specified that the resident was to be weighed upon admission and then weekly for four weeks, in accordance with facility protocol. However, a review of the clinical record, medication and treatment administration records, and weight logs revealed that only one weight was documented, which was entered by a dietary consultant using a previous hospital record rather than an actual weight taken at the facility. Interviews with staff, including CNAs, a registered dietician, and the dietary consultant, confirmed that the expected process was for CNAs or nurses to obtain and document resident weights in the electronic medical record. The dietary consultant clarified that her entry was a placeholder based on hospital data, not a current assessment. There was no documentation of the resident refusing weight assessments, and staff acknowledged that the required weekly weights were not performed as ordered. The facility's policy required monitoring and recording of resident weights to detect undesirable or unintended weight changes. Both the current and former DONs confirmed that the resident's weight monitoring order was not followed, and that the omission did not meet facility expectations. The lack of documented weights meant that the resident's nutritional status and response to enteral feeding could not be properly monitored during the relevant period.
Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to provide wound care as ordered by a physician for two residents, leading to a deficiency in care. Resident #1, who was cognitively intact, was supposed to have wound care on her right surgical area every three days. However, records showed that between November 19, 2024, and December 4, 2024, the wound care was not provided as frequently as ordered. Interviews with the resident and staff confirmed that the bandage had not been changed according to the schedule, with the last change noted on November 29, 2024. Staff admitted to signing off on care that was not provided, indicating a lapse in following the prescribed wound care regimen. Resident #2, diagnosed with osteomyelitis and cellulitis, also did not receive wound care as ordered. The physician's orders required wound care to the right ankle every three days, but observations on December 4, 2024, revealed a blood-soaked bandage dated November 28, 2024. This indicated that the wound care was overdue. Staff acknowledged the oversight, noting that the bandage needed changing and that the outgoing nurse had not completed the task during her shift. The facility's policy on wound care documentation was not adhered to, as staff documented care that was not provided. The policy required that wound care be documented after it was given, ensuring accuracy and completeness in the medical records. The failure to follow these procedures could lead to potential wound infections, as noted by staff during interviews.
Deficient Shower and Nail Care Documentation
Penalty
Summary
The facility failed to provide adequate nail care and shower assistance to two residents, leading to concerns about poor hygiene and potential infection. Resident #41, who has chronic kidney disease, Type II diabetes, and an acquired absence of the left leg below the knee, was observed to have long, stained fingernails with dirt underneath. The resident's care plan indicated a need for substantial assistance with bathing, yet the shower task sheets for March and April 2024 showed that the resident received only one shower per week, contrary to the facility's policy of two showers per week. There was no documentation of showers or nail care being offered or refused during this period. Interviews with staff revealed inconsistencies in documentation and monitoring of shower and nail care. A CNA stated that showers, which include nail care, were scheduled twice a week, and any refusals should be documented. However, the Medical Records Manager could not find any shower sheet forms for the last two weeks for Resident #41. The DON acknowledged the issue with documentation and stated that both task sheets and shower sheet forms were being used to ensure proper record-keeping. Despite these measures, the Direct Care Coordinator responsible for reviewing these forms was occupied with other duties, leading to lapses in monitoring and documentation.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff used appropriate enhanced barrier precautions (EBP) for two residents, which could result in the transmission of infections. Resident #172, who was admitted with acute cystitis and acute kidney failure, had an indwelling catheter for bladder outlet obstruction. During an observation, a certified nursing assistant (CNA) performed catheter care without wearing a gown, despite handling the catheter and performing high-contact care activities. The CNA washed her hands and donned gloves but did not follow the EBP guidelines that require wearing a gown during such procedures. Similarly, Resident #23, admitted with generalized muscle weakness and urinary incontinence, also received catheter care without the CNA wearing a gown. The CNA followed hand hygiene protocols and used gloves but did not adhere to the EBP guidelines. There were no signs posted to indicate the necessary personal protective equipment (PPE) for catheter care, and the CNA confirmed that gowns were only worn when a resident was on isolation. Interviews with the Director of Nursing (DON) and the President of Clinical Operations revealed a lack of training on PPE requirements for high-contact care activities involving residents with indwelling medical devices. The facility's infection control policy required staff education on infection control and isolation precautions, but the DON admitted that training on the new EBP guidelines had not been provided. The CMS guidance on EBP, updated in March 2024, emphasized the need for gowns and gloves during high-contact care activities, regardless of the resident's multidrug-resistant organism status.
Lack of Physician Order for Indwelling Catheter
Penalty
Summary
The facility failed to ensure there was a physician order for the use of an indwelling catheter for a resident, which could result in inappropriate use of the catheter for residents who do not need them. The resident was admitted with diagnoses of acute cystitis without hematuria and acute kidney failure. Despite the care plan indicating the presence of an indwelling catheter for bladder outlet obstruction, there was no physician order for the catheter from the time of admission until several days later. The Minimum Data Set (MDS) assessment did not code for an indwelling catheter, and the history and physical progress note did not document the presence of the catheter. Observations and interviews with staff revealed that the resident had an indwelling catheter, but the clinical record lacked a physician order for its use. A CNA was observed performing catheter care, and an LPN confirmed the absence of a physician order during a review of the electronic record. The Director of Nursing stated that a physician order was necessary for the use of an indwelling catheter and that staff should verify admission orders and contact the physician if needed. The facility's policy required documentation of clinical indications for catheter use prior to insertion and ongoing assessment of the need for the catheter.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 33 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cottonwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Haven Of Camp Verde | 15.9 mi | ★★★★★ | 10 | 0 |
| Haven Of Sedona | 16.2 mi | ★★★★★ | 20 | 0 |
| Prescott Valley Nursing & Rehabilitation | 19.8 mi | ★★★★★ | 3 | 0 |
| Mountain View Manor | 26.1 mi | ★★★★★ | 0 | 0 |
| Granite Creek Health & Rehabilitation Center | 27.8 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.