Cottonwood Rehabilitation and Healthcare Center

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Construction Deficiencies

Install noncombustible or limited-combustible interior walls.

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Egress Deficiencies

Install proper backup exit lighting.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

*** CITATION TEXT NOT FOUND *** A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required.

Christmas decorations: destructive testing. We tested multiple decorations and found that 1 green garland was not being treated properly. This garland was removed before the survey ended. The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag # K 000) are informational only and represent the facility' s general characteristics. The facility is a 37,050-square-foot facility consisting of 40 resident rooms and supporting services. It is a one-story, slab-on-grade, without a basement, Type II (111) construction. It is classified as fully protected by a N.. Through document review and observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13. This was evidenced by1) The hydraulic information plate is incorrect and needs to reflect the proper design criteria from the drawings. It also lacks a general information sign.NFPA 101, 9.7.5 Maintenance and Testing.All automatic sprinkler and standpipe systems required by this Code sh.. Through document review during the survey, it was determined that the facility failed to maintain the electrical systems in accordance with NFPA 99. This was evidenced by:1) Receptacle Testing (99 6.3.4.1): The record does not meet NFPA 99 requirementsNFPA 996.3.4.2 Record Keeping.6.3.4.2.1* General.6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modifications.6.3.4.2.1.2 At a minimum, t.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 80, and 105. This was evidenced by:1) Fire Dampers (4-6 years)(101 8.5.5.4.1 & 80 19.4): Not ProvidedNFPA 101 8.5.5.4.1 Air-conditioning, heating, ventilating ductwork, and related equipment, including smoke dampers and combination fire and smoke dampers, shall be installed in accordance with.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) Fire Safety Plan (101 19.7.2.2): This plan was not provided per NFPA 101 requirements, and the evacuation maps do not show smoke compartment walls.NFPA 101 19.7.1 Evacuation and Relocation Plan and Fire Drills.19.7.1.1 The administration of every health care occupancy sha.. Through observation during the survey, it was determined that the facility failed to maintain hazardous areas in accordance with NFPA 101. This was evidenced by:1) The maintenance office deemed hazardous needs door closure2) The janitor closet main needs to reinstall the door closure 3) The kitchen mechanical room needs fire sealant around ceiling penetrations4) The furnace mechanical room needs the ceiling repaired, smoke-tight NFPA 101 19.3.2.1.2* W.. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) Smoking (101 19.7.4): There are designated areas; however, during the survey, it was seen that staff are not using the designated areas with approved trash and cigarette receptacles. We need to make this area designated and compliant or have staff smoke in approved areas.NFPA 101 1..

A recertification survey was conducted from 11/18/24 to 11/21/24. Two deficiencies were cited. An Emergency Preparedness survey was conducted from 11/18/24 to 11/21/24. No deficiencies were cited. Based on interviews and record review, the facility failed to employ an infection preventionist (IP) who had completed specialized training in infection prevention and control which had the potential to affect all residents residing in the facility at the time of the survey.Specifically, the facility failed to have a qualified IP involved with the facility' s infection prevention and control program. Findings include: I. Facility policy and procedure The Infection Preventionist policy, revised September 2022, was provided by the nursing home administrator (NHA) on 11/21/24 at 8:25 a.m. The policy read in pertinent part, "The IP is professionally trained in nursing, medical technology, microbiology, epidemiology, or other related field with at least the following professional training:-A nurse must have earned a certificate/diploma in nursing; and,-A medical technologist must have earned at least an associate' s degree in medical technology or clinical laboratory science. "The IP is employed on site and at least.. Based on record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for one (#14) of three residents reviewed for behavioral and emotional status out of 22 sample residents. Specifically, the facility failed to coordinate timely necessary behavioral, mental and emotional health care and services for Resident #14. Findings include: I. Resident #14 A. Resident status Resident #14, age 65, was admitted on 11/3/23. According to the November 2024 computerized physician orders (CPO), diagnoses included Arnold-Chiari syndrome with hydrocephalus (a condition where the lower part of the brain protrudes into the spinal canal causing a blockage in the flow of cerebrospinal fluid and leading to a buildup of fluid in the brain), anxiety disorder, depression, insomnia, other complicated headache syndrome, cognitive communication deficit, unspecified dementia, severe, wi..

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention' s (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/22/2024 and 01/28/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.