Haven of Cottonwood: Wound Tracking Failures - AZ
The resident came in from a hospital with six documented wounds: three on the left leg, two on the right, and one on the left ankle. The discharging hospital had measured each one. The largest, on the left posterior calf, ran 13 centimeters long and 9 centimeters wide. Another on the left medial ankle measured 6 centimeters by 2. The right lower leg had a wound 6 centimeters by 4.
When Haven of Cottonwood completed its Weekly Skin and Wound Assessment on June 12, 2025, the form listed wounds on the right toes. That was it.
The facility's director of nursing reviewed that assessment during the inspection and said it did not meet her expectations. She said she could not tell from the form what size the wounds were, whether there was drainage, or whether any odors were present. "There is a possibility," she told inspectors, "that something could have been missed."
That is not a small concession. Wound drainage and odor are among the primary indicators of infection. Size measurements taken week over week are how clinicians determine whether a wound is closing or worsening. Without that documentation, there is no reliable way to know what was happening to this resident's skin during the weeks those wounds went unrecorded.
A clinical resource identified in the inspection report as Staff #40 told inspectors on August 26, 2025, that weekly skin and wound assessments are supposed to include descriptors and measurements specifically to track whether wounds are healing or not healing. That is the purpose of the form. The June 12 assessment served none of it.
The facility's own wound management policy, in place since 2014, is explicit. It calls for a thorough head-to-toe skin assessment on admission and at least weekly after that. For residents with active wounds, the policy requires weekly review, documentation of measurements, exudate, odor, wound bed description, periwound condition, and treatment. Each entry goes into the electronic health record. The policy does not leave room for a form that lists only one area of the body when six wounds are present elsewhere.
What the director of nursing described as an expectation that wasn't met, the facility's own decade-old policy describes as a requirement.
The inspection, conducted on August 27, 2025, was a complaint investigation. CMS rated the violation at the level of minimal harm or potential for actual harm, with few residents affected. The citation falls under F0684, which covers the standard of care residents are entitled to receive.
The gap between what the hospital handed off and what the facility documented is not subtle. The hospital measured six wounds across both legs. The facility's first weekly assessment found wounds on the toes. The director of nursing, reviewing her own staff's work, said she couldn't reconstruct from that record whether the wounds were improving, stable, or getting worse.
For a resident who arrived with open wounds on both legs, that is the one question the record existed to answer.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Haven of Cottonwood from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 4, 2026 · Our methodology
HAVEN OF COTTONWOOD in COTTONWOOD, AZ was cited for violations during a health inspection on August 27, 2025.
The resident came in from a hospital with six documented wounds: three on the left leg, two on the right, and one on the left ankle.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.