Inspection visit
Inspection
Citations
20 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0036GeneralS&S Cno actual harm
Establish emergency prep training and testing.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
- 0004GeneralS&S Cno actual harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0013GeneralS&S Cno actual harm
Develop Emergency Preparedness policies and procedures.
- 0029GeneralS&S Cno actual harm
Develop a communication plan.
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F761 - Labeling of Drugs and Biologicals
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.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
F880 - Infection Control
Provide and implement an infection prevention and control program.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F758 - Medication Errors
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.
F802 - Staffing
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
FAQ · About this visit
Common questions about this visit
What happened during the August 15, 2024 survey of COTTONWOOD HEALTHCARE CENTER?
This was a inspection survey of COTTONWOOD HEALTHCARE CENTER on August 15, 2024. The surveyor cited 20 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at COTTONWOOD HEALTHCARE CENTER on August 15, 2024?
Yes, 20 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Establish emergency prep training and testing."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.