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🔎 Cottonwood Health And Rehabilitation

Inspection Results


Inspection Overview

Cottonwood Health And Rehabilitation has been cited for a total of 41 deficiencies since we began saving each survey.

In Wyoming, the average facility has **29.63 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: E

Have enough outside ventilation via a window or mechanical ventilation, or both.

Survey Date: 2024-10-10
Correction Date: 2024-11-24
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2024-10-10
Correction Date: 2024-11-24
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2024-10-10
Correction Date: 2024-11-24
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2024-10-10
Correction Date: 2024-11-24
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Survey Date: 2024-10-10
Correction Date: 2024-11-01
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2024-10-10
Correction Date: 2024-11-08
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2024-10-10
Correction Date: 2024-11-24
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: G

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2024-05-22
Correction Date: 2024-06-13
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2023-07-27
Correction Date: 2023-08-24
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2023-07-27
Correction Date: 2023-08-24
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2023-07-27
Correction Date: 2023-08-24
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Survey Date: 2023-07-27
Correction Date: 2023-08-24
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-07-27
Correction Date: 2023-08-24
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2023-07-27
Correction Date: 2023-08-24
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey Date: 2023-07-27
Correction Date: 2023-08-24
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: G

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2023-07-27
Correction Date: 2023-07-19
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2023-03-14
Correction Date: 2023-04-17
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2023-03-14
Correction Date: 2023-04-17
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2023-03-14
Correction Date: 2023-04-17
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2022-11-30
Correction Date: 2023-01-01
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2022-11-30
Correction Date: 2023-01-01
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2022-06-09
Correction Date: 2022-07-13
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2022-06-09
Correction Date: 2022-07-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2022-06-09
Correction Date: 2022-07-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide activities to meet all resident's needs.

Survey Date: 2022-06-09
Correction Date: 2022-07-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: B

Post nurse staffing information every day.

Survey Date: 2022-06-09
Correction Date: 2022-07-13
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2022-06-09
Correction Date: 2022-07-13
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2022-06-09
Correction Date: 2022-07-13
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2022-02-23
Correction Date: 2022-04-08
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: C

Ensure staff are vaccinated for COVID-19

Survey Date: 2022-02-23
Correction Date: 2022-04-08
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: F

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Survey Date: 2021-04-22
Correction Date: 2021-05-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Survey Date: 2021-04-22
Correction Date: 2021-05-25
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Survey Date: 2021-04-22
Correction Date: 2021-05-25
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2021-04-22
Correction Date: 2021-05-25
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2021-04-22
Correction Date: 2021-05-25
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2021-04-22
Correction Date: 2021-05-21
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-04-22
Correction Date: 2021-05-25
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Survey Date: 2020-02-21
Correction Date: 2020-03-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Survey Date: 2020-02-21
Correction Date: 2020-03-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2020-02-21
Correction Date: 2020-03-22
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2020-02-21
Correction Date: 2020-03-22
Category: Infection Control Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**