Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Cottonwood Healthcare Center during CMS and state inspections, most recent first.
Staff disposed of meal tray tickets containing residents' names and diet information in general trash bins accessible to the public, rather than following the expected procedure of collecting and shredding them, resulting in a failure to protect resident confidentiality.
Surveyors found that medications, including loose pills and opened inhalers and eye drops, were not properly labeled or stored in a medication cart. An LPN and the DON confirmed that loose pills were present, and several opened medications lacked required date labels or were not discarded after the recommended period, contrary to facility policy and professional standards.
Surveyors found that the facility's medication error rate was 5 percent or greater, indicating a failure to maintain medication administration accuracy within regulatory standards.
Multiple infection control deficiencies were identified, including a resident's uncovered catheter bag left on the floor, another resident's nebulizer tubing not changed weekly as required, and staff entering a contact isolation room without wearing the mandated PPE. These actions were inconsistent with facility policy and infection prevention standards.
A resident in need of pain management did not receive safe and appropriate pain control services, as the facility failed to meet the resident's pain management needs.
Two residents received controlled pain medication that was signed out from the Controlled Drug Record but not documented in the Medication Administration Record, as confirmed by staff interviews and record review. Both residents had intact cognition and relevant medical conditions, and facility policy requires dual documentation for controlled substances.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition at the time.
A resident with encephalopathy and pneumonia was not administered Dornase Alfa as prescribed on nine occasions, and the physician was not informed of the medication's unavailability. The facility's policy required physician notification when medications were unavailable, which was not followed.
A resident's nasal cannula was found uncovered and undated on the side of the bed, contrary to the facility's infection control policy. The resident, with a history of congestive heart failure and acute respiratory failure, was aware that the cannula should be stored in a clear bag. The LN confirmed the improper storage, and the DON stated the expectation for proper storage to prevent contamination.
A resident with moderate cognitive impairment and mobility assistance needs was unable to access the call light, which was found on the floor under the bed. The resident had been looking for the call button for 2-3 days. The DON confirmed the call button should be within reach, and the facility's policy requires call devices to be placed within reach before leaving the room.
A resident with severe cognitive impairment physically abused another resident, resulting in an injury. The incident occurred when staff heard yelling and found the aggressive resident hitting and grabbing the other resident, causing an abrasion. The facility's policy requires reporting such altercations.
A resident in a LTC facility was subjected to undignified treatment when a CNA raised her voice and used profanity during a dining room altercation. The resident, who was cognitively intact, felt scared by the CNA's behavior. Witnesses confirmed the CNA's inappropriate language and actions, which violated the facility's policy on resident rights.
The facility failed to store medications properly, with expired sodium chloride found in the dispensing system and misplaced medications in carts, potentially leading to missed doses. A licensed nurse and the DON confirmed these findings, highlighting a lapse in adherence to medication storage policies.
The facility failed to ensure the competency of its food and nutrition services, affecting 87 residents. Dietary staff did not know the correct chlorine concentration for dishwashing and did not follow standardized recipes for green beans and pureed bread, leading to potential food contamination and nutritional inconsistencies.
The facility failed to store food properly, with expired items and unlabeled open food found in the kitchen. Additionally, there was missing documentation for testing the concentration of ammonium in the sanitizer for one shift, as confirmed by the Dietary Manager.
The facility did not ensure the QAA Committee met quarterly with required members, as the committee failed to meet in the first quarter of 2024, and the MD and DON missed two meetings. The absence of regular meetings and key members' input could delay feedback and priorities. The Administrator confirmed these issues, highlighting the need for the MD's clinical feedback.
Two residents in an LTC facility were inaccurately assessed, impacting their care plans. One resident's MDS failed to reflect behavioral issues despite documented episodes of resisting care and verbal outbursts. Another resident's MDS inaccurately indicated they were not receiving hemodialysis, despite having a catheter and physician's orders for the procedure. Staff interviews confirmed these inaccuracies, which could have affected the residents' care.
The facility failed to create comprehensive care plans for two residents, one with moisture-associated skin damage (MASD) and another using a wander guard for elopement risk. The care plans lacked necessary interventions and documentation, as confirmed by the DON, contrary to the facility's policy requiring person-centered care plans with measurable objectives.
A resident developed moisture-associated skin damage and a right hip pressure ulcer, but the facility failed to revise the care plan in a timely manner. Despite documented changes in the resident's condition, the care plan was not updated to include new interventions. The DON confirmed that the care plan should have been updated quarterly and as needed, in accordance with the facility's policy.
A resident with joint contracture and muscle wasting was not properly assessed for skin conditions, leading to the development of a pressure ulcer. Initial assessments showed no pressure ulcers, but later records indicated skin tears and moisture-associated damage. Despite this, the resident's skin was inaccurately assessed as intact, and a comprehensive assessment was not conducted. The resident eventually developed an unstageable pressure ulcer, confirmed by staff interviews.
A resident with heart failure was administered oxygen at 5L/min instead of the prescribed 2L/min, as observed during a survey. The resident expressed discomfort, and a nurse confirmed the discrepancy. The facility's policy requires adherence to physician orders, which was not followed in this case.
The facility did not complete annual performance evaluations for three CNAs, with one CNA having no evaluation since hire and others overdue. The DSD confirmed the evaluations were overdue, and the DON highlighted their importance for feedback and care improvement. Facility policy requires annual evaluations.
A facility failed to act on a Consultant Pharmacist's recommendation regarding a resident's use of risperidone, an antipsychotic medication prescribed for anxiety and depression. Despite the recommendation to re-evaluate the medication regimen, the physician disagreed without documenting the reason, and the medication continued to be administered without proper indication. The facility's policy requires such recommendations to be documented and acted upon, which was not followed.
A resident was prescribed risperidone for adjustment disorder without an adequate indication, contrary to the facility's policy. Despite a Consultant Pharmacist's recommendation to re-evaluate the medication order, the physician and nurse practitioner disagreed and did not document their reasoning, leading to continuous administration of the medication without proper justification.
A dietary staff member failed to follow infection control practices by not changing gloves or performing hand hygiene after cleaning a soiled kitchen cart and before handling clean items. This was confirmed by the Dietary Manager, who acknowledged the breach of the facility's Glove Use Policy.
A resident with a history of stroke and mobility issues was left soiled and undignified after a CNA refused to assist with personal hygiene. Despite the resident's clear communication and need for help, the CNA insisted he manage alone, leaving him distressed. The incident was witnessed by student nurses and confirmed by the DON, highlighting a breach in the facility's policy on resident dignity.
Failure to Protect Resident Confidentiality in Meal Ticket Disposal
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical information when meal tray tickets containing residents' names and diet information were disposed of in the general kitchen garbage. During observation, a Dietary Aide was seen discarding these meal tickets into a garbage can, which was later emptied into an outside bin accessible to the public. The Dietary Aide confirmed that this was the usual practice for meal tickets left on trays. The Dietary Supervisor stated that the expected procedure was for staff to collect meal tickets and bring them to the supervisor's office for shredding, acknowledging that the tickets contained sensitive resident information. Review of facility policy confirmed residents' rights to confidential treatment of health records.
Improper Medication Labeling and Storage
Penalty
Summary
Surveyors observed that the facility failed to ensure medications were properly labeled and stored according to facility policies and accepted professional standards. Specifically, five loose pills were found in a medication cart, which were confirmed by a licensed nurse, who acknowledged that staff would not be able to identify the medications. Both the consultant pharmacist and the director of nursing confirmed that loose pills should not be present in medication carts due to safety concerns and the need to keep carts clean. Additionally, opened Polymyxin B-tmp eye drops, Incruse Ellipta inhaler, and Symbicort inhaler were found without opened date labels, contrary to facility policy and manufacturer instructions, which require labeling with the date opened to ensure timely disposal. A used Latanoprost eye drop with an opened date exceeding 28 days was also found in the medication cart, despite the requirement to discard after 28 days. Both the consultant pharmacist and the director of nursing confirmed that these medications should have been labeled and discarded as per protocol.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than acceptable rate of medication errors. The deficiency was based on the surveyors' findings that the facility did not maintain medication error rates below the required threshold.
Infection Control Lapses in Catheter Care, Nebulizer Equipment, and PPE Use
Penalty
Summary
The facility failed to maintain safe and sanitary care practices for its residents, as evidenced by multiple infection control lapses. One resident with a history of sepsis, urinary calculus, and kidney infections was observed with an uncovered nephrostomy bag hanging from the bedrail and an uncovered urinary catheter bag lying on the floor. A licensed nurse confirmed that catheter bags should not touch the ground for infection control reasons, and the facility's policy also requires catheter tubing and drainage bags to be kept off the floor. Another resident, diagnosed with dementia, COPD, and congestive heart failure, was found to have nebulizer face mask tubing labeled with a date more than seven weeks prior, despite facility policy and staff statements that such equipment should be changed weekly. Both the infection preventionist and the DON confirmed that the tubing should be changed every seven days to prevent respiratory infections, but this was not done in accordance with the policy. Additionally, staff failed to adhere to required personal protective equipment (PPE) protocols for a resident on contact isolation precautions due to VRE and possible C. difficile infection. Despite signage indicating that gloves and gowns must be worn upon entering the room, staff members, including activities staff and a CNA, entered the room without the required PPE. The infection preventionist confirmed that the facility's practice was to wear PPE only when directly caring for the infected resident, which contradicted both facility policy and CDC guidance requiring PPE upon every entry into the room.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The facility failed to provide the necessary care to address the resident's pain needs as required.
Failure to Document Controlled Drug Administration in Both CDR and MAR
Penalty
Summary
The facility failed to ensure safe and effective pharmaceutical services for two residents when controlled drug administrations were not properly documented in both the Controlled Drug Record (CDR) and the Medication Administration Record (MAR). For one resident with a history of femur fracture and muscle weakness, Norco was signed out from the CDR on three occasions, but these administrations were not recorded on the MAR. For another resident with Parkinson's disease, diabetic polyneuropathy, and muscle weakness, Norco was also signed out from the CDR on two occasions without corresponding documentation on the MAR. Both residents were assessed as having intact cognition at the time of the incidents. Interviews with nursing staff and facility leadership confirmed that the expected practice is to document controlled medication administration in both the CDR and MAR. Facility policy also requires this dual documentation. The discrepancies were identified during a random audit and were acknowledged by both the licensed nurse involved and the Director of Nursing, who described the correct process for administering and documenting controlled drugs. The failure to document these administrations in the MAR was directly observed and confirmed through record review and staff interviews.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Notify Physician of Unavailable Medication
Penalty
Summary
The facility failed to ensure that services met professional standards of quality for a resident when the resident's physician was not informed about a medication that was unavailable and not administered as prescribed. The resident, who was admitted with multiple diagnoses including encephalopathy and pneumonia due to pseudomonas, was prescribed Dornase Alfa Inhalation Solution to be administered twice daily. However, the Medication Administration Record (MAR) indicated that the medication was not administered on nine occasions, with notes citing reasons such as 'med not delivered this shift,' 'on order,' 'N/A,' and 'unavailable.' There was no documented evidence in the resident's clinical records that the physician was notified about the medication not being available for administration. The Director of Nursing confirmed the medication was not given nine times and acknowledged the lack of documentation regarding physician notification. The facility's policy and procedure required medications to be administered as prescribed and for the prescriber to be contacted if the medication would not be available, which was not adhered to in this case.
Inadequate Infection Control for Nasal Cannula
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for Resident 3, who was observed with a nasal cannula left uncovered and undated on the side of the bed when not in use. Resident 3, who was admitted with multiple diagnoses including congestive heart failure and acute respiratory failure with hypoxia, was cognitively intact and aware that the nasal cannula should be stored in a clear bag. However, the nasal cannula was found between the side rail and the mattress, contrary to the facility's policy. During an interview, the Licensed Nurse confirmed the improper storage of the nasal cannula and acknowledged that it should have been placed in a plastic bag to prevent contamination. The Director of Nursing also stated that the nasal cannula should be dated and stored properly when not in use, as per the facility's policy, which mandates changing the oxygen cannulae and tubing every seven days and storing them in a plastic bag when not in use. This oversight increased the risk of cross-contamination, as noted in the report.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was accessible for a resident who was not physically able to use the call light when it was out of reach. The resident, who had been admitted with multiple diagnoses including orthopedic aftercare following surgical amputation and acquired absence of the left foot, had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. The resident required substantial to maximal assistance for mobility needs and had a care plan indicating a self-care deficit requiring assistance in various personal care activities. During an observation, the resident was found pointing with his left index finger to call the attention of a state surveyor, as his call button was on the floor underneath his bed. The resident stated he had been looking for the call button for 2-3 days. The Director of Nursing (DON) confirmed the call button should not be on the floor and that the expectation was for call lights to be within reach at all times. A Certified Nursing Assistant (CNA) mentioned that she normally clips the call button to the blanket but noted that the resident was constantly moving, and she had repositioned him an hour prior. The facility's policy indicated that the call device should be placed within the resident's reach before leaving the room.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when another resident, who had severe cognitive impairment, hit and grabbed the resident, resulting in an injury. Resident 1, who had intact cognition, was admitted with diagnoses including heart failure and anxiety disorder. Resident 2, admitted with a stroke, depression, and communication difficulty due to cognitive impairment, had a BIMS score indicating severe cognitive impairment. On the evening of December 15, 2024, staff heard Resident 1 yelling and found Resident 2 striking Resident 1 on the arms and legs, causing an abrasion to Resident 1's left forearm. Interviews and record reviews revealed that Resident 1's arm was bruised and sore following the incident. A Licensed Nurse confirmed witnessing Resident 2 slapping Resident 1's legs and acting aggressively, making it difficult to redirect Resident 2. The Director of Nursing acknowledged that residents have the right to be free from any form of abuse. The facility's policy on resident-to-resident altercations requires reporting any willful action resulting in physical injury, such as hitting or slapping.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The incident occurred during lunchtime in the dining room, where the resident was engaged in a conversation with another resident about an upcoming surgery. The CNA, who was feeding another resident, intervened in the conversation and began to raise her voice and use inappropriate language towards the resident, telling her to mind her own business and using profanity. The resident, who was cognitively intact and able to communicate effectively, reported feeling scared during the altercation. Witnesses, including other residents, confirmed the CNA's use of profanity and aggressive behavior. One resident recalled the CNA telling the resident that if she did not like the facility, she could leave. Another resident, who was being assisted by the CNA at the time, expressed frustration that the CNA stopped feeding her to engage in the argument. The facility's policy on resident rights, which emphasizes treating residents with kindness, respect, and dignity, was not adhered to in this situation. The incident was reported to the Director of Nursing, and interviews with residents corroborated the account of the CNA's inappropriate conduct. The failure to uphold the resident's right to a dignified existence and respectful treatment was evident in the CNA's actions during the incident.
Improper Medication Storage and Expired Drugs Found
Penalty
Summary
The facility failed to ensure proper storage of medications, which was identified during an observation and interview process. Two bottles of sodium chloride, used for diluting medications, were found expired in the automatic dispensing system within the medication room of stations 1 and 2. The expiration date was verified by a licensed nurse, indicating a lapse in monitoring and replacing expired medications. Additionally, multiple medications were discovered improperly stored at the bottom of medication carts 3 and 5, behind the drawers. This was confirmed during observations and interviews with a licensed nurse, who acknowledged that residents might have missed scheduled doses due to this oversight. The Director of Nursing also confirmed that the pharmacy staff should have checked and replaced expired medications, as per the facility's policy and procedure on medication storage.
Deficiencies in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure the competency of its food and nutrition services, affecting a census of 87 residents. Dietary Staff 2 (DS 2) was unable to state the correct chlorine sanitizing concentration required for manual dishwashing, as per the facility's policy. This policy mandates that the sanitizing solution in the third compartment of the dishwashing process must be tested with a test strip and recorded, with a required concentration of 200 parts per million. DS 2's lack of knowledge in this area could potentially lead to improper sanitization of dishes, increasing the risk of food contamination. Additionally, Dietary [NAME] 1 (DC 1) did not adhere to standardized recipes when preparing green beans, failing to add the required seasonings of salt, pepper, and butter, which are specified in the facility's recipe for seasoned green beans. This resulted in inconsistencies in the flavor and nutritional content of the food served to residents. Furthermore, DC 2 did not follow the recipe for pureed bread, using incorrect measurements of ingredients, which was confirmed by Dietary Manager 1 (DM 1). The absence of a policy mandating adherence to recipes was noted, contributing to these deficiencies in food preparation.
Deficiency in Food Storage and Sanitizer Documentation
Penalty
Summary
The facility failed to store food in a sanitary manner, as observed during a survey. Seven bags of cookies and a seasoning bottle were found stored past their expiration dates. Additionally, several food items, including salad oil, quick creamy wheat, and corn starch, were opened but lacked proper labeling with open dates and use-by dates. The Dietary Manager confirmed that these items should have been labeled and expired items discarded, as per the facility's policy on Sanitation and Infection Control. Furthermore, the facility did not maintain proper documentation for testing the concentration of ammonium in the quaternary sanitizer for one shift. The Dietary Manager acknowledged the missing documentation and stated there was no policy for ammonium concentration testing. The facility's Quaternary Ammonium Log required testing and recording the concentration of the sanitizer at least once per shift, but this was not done for one shift, as confirmed by the Dietary Manager.
Failure to Conduct Quarterly QAA Meetings with Required Members
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) Committee met at least quarterly with the required members for a census of 87 residents. Specifically, the QAA committee did not convene in the first quarter of 2024, and both the Medical Director (MD) and Director of Nursing (DON) were absent from two meetings. A review of the Class Attendance Roster from November 2023 indicated that a Quality Assurance and Performance Improvement (QAPI) meeting was held in October 2023, but the DON and MD did not attend. Additionally, a QA Meeting document from April 2024 confirmed a QAA meeting was held, and another document from August 2024 showed that the MD did not attend the meeting held on August 13, 2024. During an interview, the Administrator acknowledged that the QAA committee meetings were not held quarterly as required and confirmed the irregular attendance of the DON and MD. The Administrator expressed concern that the absence of regular QAA meetings and the lack of input from the DON and MD could result in delayed feedback and priorities being overlooked. The Administrator emphasized the necessity of the MD's presence for clinical feedback and direction.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to accurately assess two residents, leading to deficiencies in identifying their care needs. Resident 9's Minimum Data Set (MDS) inaccurately indicated no behavioral symptoms, despite records showing numerous episodes of resisting care and behavioral disturbances, including attempts to hit staff and verbal outbursts. Interviews with facility staff, including the Licensed Nurse, Director of Social Services, MDS Coordinator, and Director of Nursing, confirmed the inaccuracies in Resident 9's MDS, which could have impacted his plan of care. The resident was on medication for mood disorder, and his care plan documented significant behavioral issues that were not reflected in the MDS. Similarly, Resident 79's MDS inaccurately reported that the resident was not receiving hemodialysis, despite having a hemodialysis catheter and physician's orders for the procedure three times a week. The MDS Coordinator acknowledged the inaccuracy, which might have led to missed care and treatment. The Director of Nursing stated that staff should have maintained accurate assessment records in accordance with facility policy. The facility's policy requires all personnel completing any portion of the MDS to sign and certify the accuracy of their assessments.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents, leading to deficiencies in addressing their specific needs. Resident 14 was admitted with diagnoses including joint contracture and muscle wasting. Despite documentation indicating the presence of moisture-associated skin damage (MASD), the care plan did not include interventions for MASD, such as applying barrier cream. The Director of Nursing (DON) confirmed the absence of a care plan for MASD, acknowledging that without it, nurses might be unable to identify and prevent further skin breakdown. Resident 82, diagnosed with dementia and agitation, was observed wearing a wander guard due to an elopement risk. However, the care plan did not address the use of the wander guard, despite an order for its use being documented. The DON confirmed that the care plan should have included the wander guard from the time it was ordered. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables to meet residents' needs, which was not adhered to in these cases.
Failure to Revise Care Plan for Resident with Skin Damage
Penalty
Summary
The facility failed to revise the care plan interventions in a timely manner following a change in condition for Resident 14, who developed moisture-associated skin damage (MASD) and a right hip pressure ulcer. Resident 14 was admitted with diagnoses including joint contracture and muscle wasting and atrophy. Despite the development of MASD noted in the Nurses Weekly Progress Notes and a deterioration in the right hip skin condition documented in the SBAR Communication Form, the care plan was not updated to reflect these changes. The care plan, last revised several months prior, did not incorporate new interventions to address the resident's deteriorating skin condition. During an interview, the Director of Nursing confirmed that the care plan should have been updated quarterly and as needed to personalize interventions when there were changes in care. The facility's policy on Comprehensive Person-Centered Care Plans mandates that the Interdisciplinary Team must review and update the care plan when there is a significant change in the resident's condition or when the desired outcome is not met. The failure to revise the care plan decreased the facility's potential to provide Resident 14 with a person-centered care plan and evaluate its effectiveness.
Failure to Assess and Monitor Skin Condition Leads to Pressure Ulcer
Penalty
Summary
The facility failed to properly assess and monitor the skin condition of a resident, leading to the development of a pressure ulcer. The resident, who was admitted with conditions such as joint contracture and muscle wasting, initially had no pressure ulcers according to the Minimum Data Set assessment. However, subsequent records indicated the presence of skin tears and moisture-associated skin damage. Despite these indications, the resident's skin condition was inaccurately assessed as clear and intact at one point, and a comprehensive head-to-toe assessment was not conducted. The situation deteriorated when a communication form noted a worsening skin condition with discoloration and non-blanchable areas, yet the resident's skin was not assessed in the following weekly progress notes. Eventually, the resident developed an unstageable pressure ulcer on the right hip. Interviews with facility staff, including a licensed nurse and the Director of Nursing, confirmed the inaccuracies in the skin assessments and acknowledged that these failures contributed to the delayed identification and intervention for the resident's pressure ulcers.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to provide respiratory care services according to professional standards for a resident, identified as Resident 244, whose administered oxygen was not consistent with the physician's order. Resident 244 was admitted with diagnoses including heart failure and had a physician's order to use oxygen continuously via nasal cannula at 2L/min. However, during an observation on August 12, 2024, Resident 244 was found to be receiving oxygen at 5L/min, which was more than double the prescribed amount. The resident expressed that the oxygen felt excessive, indicating a discrepancy between the care provided and the physician's order. Licensed Nurse 7 confirmed during an interview and record review that the oxygen was set incorrectly at 5L/min instead of the ordered 2L/min. The Director of Nursing later stated that it was expected for staff to follow physician orders to ensure proper care for residents. The facility's policy on medication and treatment orders, revised in July 2016, emphasized that orders should be consistent with safe and effective order writing. This oversight in following the physician's order decreased the facility's ability to safely provide respiratory services and increased the risk of lung problems for Resident 244.
Failure to Conduct Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete the annual performance evaluations for three of seven sampled certified nursing assistants (CNAs), specifically CNA 1, CNA 2, and CNA 3. CNA 1 was hired on 5/15/07, with the last performance evaluation completed on 7/13/22. CNA 2, hired on 5/9/23, had no performance evaluation conducted. CNA 3, hired on 4/24/17, had their last performance evaluation on 5/28/23. During interviews, the Director of Staff Development confirmed that the performance evaluations were overdue and should have been completed annually. The Director of Nursing emphasized the importance of these evaluations for providing feedback and identifying areas for improvement in resident care. The facility's policy mandates that employee job performance be reviewed and evaluated at least annually.
Failure to Address Pharmacist's Recommendation on Antipsychotic Use
Penalty
Summary
The facility failed to act on the Consultant Pharmacist's (CP) Medication Regimen Review (MRR) recommendation for a resident when the physician did not address the recommendation related to the use of risperidone, an antipsychotic medication. The resident was admitted with diagnoses including schizophrenia and was receiving psychological services. The CP identified an irregularity in the use of risperidone, as it was prescribed for anxiety and depression, and recommended that the physician re-evaluate the regimen or update the order with the appropriate indication to comply with regulations. Despite the CP's recommendation, the physician, through the nurse practitioner, disagreed with the recommendation but did not document the reason for disagreement. The Director of Nursing (DON) confirmed that the facility received the MRR recommendation and acknowledged that the risperidone was still being administered without proper documentation of the indication for its use. The facility's policy requires that recommendations from the CP be acted upon and documented, and if the attending physician does not concur, the Medical Director should be contacted, which was not done in this case.
Inadequate Indication for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication use. The resident, who was admitted with a diagnosis of schizophrenia, was prescribed risperidone, an antipsychotic medication, for adjustment disorder with mixed anxiety and depressed mood. This prescription did not have an adequate indication for use, as required by the facility's policy and procedure for psychotropic medication use. The facility's Consultant Pharmacist identified this irregularity during a medication regimen review and recommended that the physician re-evaluate the medication order to ensure compliance with regulations. Despite the Consultant Pharmacist's recommendation, the Director of Nursing confirmed that the physician and nurse practitioner disagreed with the recommendation and did not document their reasoning. Consequently, the risperidone was continuously administered to the resident without revising or updating the order to reflect an appropriate indication. This oversight placed the resident at risk for unnecessary psychotropic medication use, as the facility's policy stipulates that antipsychotic use must not be due to environmental or psychological stressors.
Infection Control Breach by Dietary Staff
Penalty
Summary
The facility failed to adhere to proper infection control practices, as observed with a dietary staff member. The staff member, while wearing gloves, was seen handling clean kitchen items on the clean side of the dishwasher. Without changing gloves or performing hand hygiene, the staff member then used a rag from a disinfecting solution to clean a soiled kitchen cart. Subsequently, the same gloves were used to handle a clean cooler and fill it with ice, before continuing dishwashing tasks. This sequence of actions was confirmed by the Dietary Manager, who acknowledged that gloves should have been changed and hands washed after cleaning tasks. The facility's Glove Use Policy, dated 2020, specifies that gloves should be changed before starting a different task and when they become soiled, such as during cleaning activities.
Resident Left Soiled Due to CNA's Inaction
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident with a history of cerebral infarction, hemiplegia, and hemiparesis. The resident, who was cognitively intact and able to communicate effectively, required assistance with personal hygiene after using the bathroom. However, CNA 1 refused to assist the resident in cleaning and pulling up his brief, leaving him soiled and with his pants down in his wheelchair. The incident was witnessed by two student nurses who reported that CNA 1 was verbally inappropriate and insisted that the resident could manage on his own, despite his visible struggle and inability to do so. The CNA's refusal to provide necessary assistance resulted in the resident being left in a soiled state, which was emotionally distressing for him. The resident expressed feeling sad about the incident, which was corroborated by the student nurses' statements and the facility's documentation. The Director of Nursing (DON) substantiated the allegation, noting that CNA 1 did not provide a statement and her employment ended on the day of the incident. The facility's policy on resident rights emphasizes treating all residents with kindness, respect, and dignity, which was not upheld in this case. The failure to assist the resident appropriately and maintain his dignity constitutes a deficiency in the standard of care provided by the facility.
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What surveyors actually found near you
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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.
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Woodland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Grove Post-acute | 0.8 mi | ★★★★★ | 15 | 0 |
| Woodland Post-acute | 1.1 mi | ★★★★★ | 25 | 0 |
| University Retirement Community At Davis | 7.8 mi | ★★★★★ | 23 | 0 |
| Courtyard Health Care Center | 8.9 mi | ★★★★★ | 7 | 0 |
| River Bend Nursing Center | 15.1 mi | ★★★★★ | 31 | 0 |
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