Cottonwood Village

Based on documentation review and interview, the manager failed to ensure policies and procedures were established, documented, and implemented that covered methods by which the assisted living facility was aware of the general or specific hereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide. Findings include: 1 . A review of facility documentation revealed a policy that covered methods by which the assisted living facility was aware of the general or specific hereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on record review, documentation review and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services and according to policies and procedures, for one of four caregivers sampled. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1 . A review of E2's personnel record revealed documentation of a skills and knowledge verification form was not available for review at the time of inspection. 2 . In an interview, E2 reported they had helped residents with various activities of daily living. 3 . A review of facility documentation revealed a policy titled "Procedures for General Staff Training." The policy stated "Before employee partners are allowed to perform any health-related tasks, the health-related services training documentation form (HS 002) must be completed, signed by the wellness director and place in the employee partners personnel file." 4 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that before providing assisted living services to a resident, a manager or caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training certification specific to adults, for one of four caregivers sampled. Findings include: 1 . A review of E2's personnel record revealed that documentation of a CPR card was not available for review at the time of inspection. 2 . In an interview, E2 reported that they had helped residents with various activities of daily living. 3 . In an exit interview, the findings were discussed with E1, and no additional information was provided. This is a repeat deficiency from the complaint investigation conducted on January 18, 2024.

Based on record review and interview, the manager failed to ensure written notification of a resident's elopement was provided to the department within 24 hours of the elopement being discovered, for one of three residents sampled. Findings include: 1 . A review of R2's medical record revealed an elopement report on October 7, 2025. However, documentation of the elopement being reported to the department was not available for review at the time of inspection. 2 . In an interview, E1 reported the facility was unaware they had to report elopement. 3 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery. Findings include: 1 . A review of personnel records revealed documentation of training in fall prevention and fall recovery. 2 . A review of facility documentation revealed documentation of a fall prevention and fall recovery program, which included when initial training is conducted and when continued competency training is conducted, was not available for review at the time of inspection. 3 . In an exit interview, the findings were discussed with E1 and no additional information was provided. 4. This is a repeat deficiency from the on-site compliance inspection conducted May 3, 2023.

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. Findings include: 1 . A review of facility documentation revealed documentation of a disaster plan review conducted at least once every 12 months was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were inaccessible to residents. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed a cleaning cart unattended in a common hallway. The cleaning cart had multiple compartments that could be locked, however the compartments were not currently locked, and the Compliance Officers were able to access the following: -A bottle of multi-purpose cleaner; -A can of "Ajax"; -A bottle of "Lysol" toilet cleaner; and -A can of "Renown" heavy-duty glass cleaner. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided. 3. This is a repeat deficiency from the on-site complaint and compliance inspection conducted July 2, 2024.

Based on record review and interview, the governing authority failed to ensure that one of five sample personnel records included documentation that a copy of the employee's current fingerprint clearance card had been obtained and verified with the Department of Public Safety (DPS), or an application for a fingerprint clearance card completed. Findings include: 1. The record for E5 (start date January 22, 2023) contained a DPS fingerprint clearance card that expired on March 20, 2024. Additionally the record contained an application for a fingerprint clearance card completed on July 1, 2024. No additional documentation was present in the record reflecting that DPS was contacted to renew the fingerprint clearance card prior to expiration. 2. During an interview, E1 acknowledged that E5 continued to provide caregiver services to residents without holding a valid fingerprint clearance card. This is a repeat deficiency from the complaint investigation conducted on August 24, 2023.

Based on record review and interview, the manager failed to ensure that four of five sample personnel records contained evidence of freedom from infectious tuberculosis (TB), on or before the date the individual began providing services to residents as specified in R9-10-113. Findings include: 1. The record for E2 (Manager Designee, hired February 14, 2022) contained documentation indicating that one TB test was administered within the 12 months prior to the date of hire. No other TB test documentation conducted within the past 12 months was found in the record. 2. The record for E3 (Manager Designee, hired April 22, 2024) contained documentation indicating that one TB test was administered within the 12 months prior to the date of hire. No other TB test documentation conducted within the past 12 months was found in the record. 3. The record for E4 (Caregiver, hired January 2, 2024) contained documentation indicating that one TB test was administered within the 12 months prior to the date of hire. No other TB test documentation conducted within the past 12 months was found in the record. 4. The record for E5 (Caregiver, hired January 22, 2023) contained documentation indicating that one TB test was administered within the 12 months prior to the date of hire. No other TB test documentation conducted within the past 12 months was found in the record. 5. During an interview, E1 acknowledged that the employees worked more than eight hours per week and the documentation did not reflect that the employee records contained evidence of freedom from TB as specified in R9-10-113, prior to providing services to residents.

Based on observation and interview, the manager failed to ensure that the premises was cleaned according to policies and procedures. Findings include: 1. Observation of the hallway carpeting in the entry of the first floor assisted living unit revealed an approximate 3' wide by 15' long section of carpeting that was dark gray in color and appeared to be heavily soiled. 2. Review of the facility policies and procedures indicated the premises will be maintained in a clean condition. 3. During an interview, E1 acknowledged the section of carpeting was discolored.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials were stored in a locked area, inaccessible to residents. Findings include: 1. Observation of the unlocked laundry room, located in the "memory unit", revealed the following poisonous or toxic materials: four bottles of Lysol Lime and Rust Clinging Gel (labeled Danger). The bottles were found stored in a white cabinet that was missing a door. The laundry room door was equipped with a lock but had been propped open with a trash can. No staff were observed near the materials at the time. 2. During an interview, E1 acknowledged that poisonous or toxic materials had not stored in a locked area, inaccessible to residents.

Based on documentation review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that include the information found in subsections a. through f. of this rule. Findings include: 1. Review of facility documentation failed to reveal information indicating that the health care institution had established and documented tuberculosis infection control documentation and activities that include subsections a. through f. of this rule. 2. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually assessing the health care institution's risk of exposure to infectious tuberculosis. Findings include: 1. Review of facility documentation failed to reveal an annual assessment of the health care institution's risk of exposure to infectious tuberculosis. 2. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on record review and interview, the manager failed to ensure for one of two sample records, that before providing services to a resident, a caregiver provided documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults. Findings include: 1. The record for E2 (hired June 19, 2023), revealed documentation of CPR and First aid certifications that expired on July 26, 2023. 2. During an interview, E1 acknowledged that the caregiver provided services to residents without documentation of first aid and CPR training certification.

Based on record review and interview the manager failed to ensure that one of four residents had a written service plan. Findings include: 1. The medical record for R3 did not contain a service plan. Based on the resident's date of admission a written service plan was required. 2. During an interview, E1 acknowledged the required documentation was not available for review.

Based on interview and record review for three of three sample records, the manager failed to ensure that a resident has a written service plan that was reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition. Findings include; 1. The record for R1 contained a service plan dated September 26, 2023 that indicated R1 was at the personal level of care and required no assistance with toileting. 2. During an interview, E3 stated, "The resident is incontinent and on hospice care. Caregivers assist (R1) with their briefs. (R1) has been like that for more than 14 days." 3. The record for R2 contained a service plan dated August 15, 2023 that indicated R2 was at the personal level of care and was independent with all hygiene and toileting needs. 4. During an interview, E3 stated, "The resident was total assistance prior to their passing. (R2) had been like that for more than 14 days." 5. The record for R4 contained a service plan dated May 16, 2023 that indicated R4 was at the personal level of care, did not require assistance with meals and was "stand by assistance" with toileting. 6. During an interview, E3 stated, "The resident is total assistance with everything including meals. (R4) has been like that for more than 14 days." 7. During an interview, E1 acknowledged that the resident's service plans were not updated within 14 days after a significant change in their condition.

Based on record review and interview, the manager failed to ensure that one of one sample resident record contained documentation of a written service plan that was reviewed and updated at least once every six months for a resident receiving personal care services. Findings include: 1. The record for R4 contained a service plan review reflecting the last service plan was completed on May 16, 2023. 2. During an interview, E1 acknowledged the service plan documentation did not reflect that the plan was reviewed and updated at least once every six months.

Based on record review and interview the manager failed to ensure for one of four sample service plans, a resident had a written service plan that when updated, was signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan. Findings include: 1. Review of the record for R1 (receiving medication administration, personal care services), revealed that the service plan dated September 26, 2023 was not signed and dated by the resident or their representative, the manager, or the nurse or medical practitioner who reviewed the service plan. 2. During an interview, E1 acknowledged the required documentation was not available for review. This is a repeat deficiency from the complaint investigation conducted on August 24, 2023.

Based on record review and interview, the governing authority failed to ensure that two of three sample personnel records included documentation that the employees had current and valid fingerprint clearance cards, or an application for a fingerprint clearance card completed, within 20 working days of employment. Findings include: 1. The record for E3 (start date as an assistant caregiver July 3, 2022) contained no documentation reflecting that the employee had a valid fingerprint clearance card or had submitted an application for fingerprint clearance to the Department of Public Safety (DPS). 2. During an interview, E1 stated, "[E3] had [E3's] prints done but I don't have a copy of [E3's] card." 3. Review of the DPS web site failed to reveal that E3 had a valid fingerprint clearance card or a fingerprint clearance card application was in process. 4. The record for E2 (hired as an assistant caregiver July 20, 2023) contained no documentation reflecting that the employee had a valid fingerprint clearance card or had submitted an application for fingerprint clearance to the DPS. 5. During an interview, E1 stated "I don't have that." 6. Review of the DPS web site failed to reveal that E2 had a valid fingerprint clearance card or a fingerprint clearance card application was in process. 7. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on record review and interview, the manager failed to ensure that an assistant caregiver interacts with residents under the supervision of a manager or caregiver. Findings include: 1. Review of the record for R1 revealed an incident report dated August 15, 2023 containing a statement by E2 that indicated in part, "I walked in room. [R1] was on the floor. I tried picking [R1] up and [R1] said no [R1] was hurt." 2. During an interview, E1 stated "E2 was alone with R1 in [R1's] room when [E2] discovered [R1] on the floor. That's when [E2] called for E3 to help." 3. Review of the record for E2 revealed that E2 was an assistant caregiver. 4. During an interview, E1 acknowledged that E2 interacted with residents without the supervision of a manager or caregiver.

Based on record review and interview, the manager failed to ensure that two of two sample resident records contained documentation of a service plan that when updated, was signed and dated by the nurse or medical practitioner who reviewed the service plan. Findings include: 1. The record for R1 (directed care, receiving medication administration services), contained a service plan dated March 30, 2023 that did not reflect the dated signature of the nurse or medical professional who reviewed the plan. 2. The record for R2 (directed care, receiving medication administration services), contained a service plan dated June 17, 2023 that did not reflect the dated signature of the nurse or medical professional who reviewed the plan. 3. During an interview, E1 acknowledged that the service plans did not reflect the dated signature of the nurse or medical professional.

Based on record review and interview, the Manager failed to ensure that a resident was treated with dignity, respect and consideration. Findings include: 1. Review of the record for R2 revealed an incident report dated August 17, 2023 that indicated O1 overheard E2 cussing at R2 and refusing to assist with care. 2. Review of the record for E2 revealed a corrective action form completed by E1 that indicated "Verbal abuse.. E2 said to R2 'F*** you, I'm not going to help you.'" 3. During an interview, E1 acknowledged E2 failed to treat R2 with dignity, respect and consideration.