Cottingham Retirement Community

Inspectors wroteBased on observation, review of the freezer and refrigerator temperature logs, interview, and policy review, the facility failed to ensure food was stored and prepared under sanitary conditions. This had the potential to affect 56 out of 56 residents who eat food prepared in the kitchen. The facility identified one (Resident #08) who did not eat food by mouth. The facility census was 57. Findings Included:Observation of the dry food storage area on 02/09/26 at 6:33 P.M. revealed a package of opened, undated sandwich buns with mold growing on one of the buns. In addition, there was an opened, undated loaf of white bread. The Dietary Supervisor #132 verified the above items and discarded them. Observation of the walk-in refrigerator in the main kitchen on 02/09/26 at 6:44 P.M. revealed a loosely covered cart of pre-prepared foods with a date of 02/03/26. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure discharge summaries were completed. This affected one (#01) of one resident reviewed for discharge. The facility census was 57.

Inspectors wroteBased on medical record review, resident interview, and staff interview, the facility failed to ensure care was coordinated with the hospice provider. This affected one (#29) of three residents reviewed for hospice services. The facility census was 57.

Inspectors wroteBased on observation, staff interview, medical record review, and review of facility policy, the facility failed to have physician orders in place for the administration of oxygen. Additionally, the facility failed to ensure appropriate oxygen in use signage was posted. This affected one (#56) of two residents reviewed for oxygen therapy. The facility census was 57.

Inspectors wroteBased on medical record review, observations, staff interview, and review of facility policy the facility failed to ensure medications were stored in an appropriate manner. This affected one (#11) of four residents reviewed for medication storage. The facility census was 57.

Inspectors wroteBased on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure proper enhanced barrier precautions were donned when completing a wound treatment. This affected one (Resident #17) of three residents reviewed for infection control. In addition, the facility failed to develop and implement a water management plan to mitigate the risk of Legionella. This had the potential to affect all residents residing in the facility. The facility census was 57. Findings Include:1. Resident #17 was admitted to facility on 04/28/25. Diagnoses included Alzheimer's Disease, infection of the skin, low back pain, depression, anxiety disorder, diabetes, hypertensive retinopathy, dermatochalasis, chronic kidney disease, diabetic retinopathy, and kidney transplant. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure timely provision of a pneumococcal vaccine to a resident once consented. This affected one (Resident #19) of five residents reviewed for pneumococcal vaccine administration. The facility census was 57. Findings Include:Review of the medical record for Resident #19 revealed an admission date of 08/06/2025. Diagnoses included unspecified dementia, chronic kidney disease, type 2 diabetes mellitus without complications, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe problems with thinking and memory. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure timely provision of COVID-19 vaccine to a resident once consented. This affected one (Resident #55) of five residents reviewed for COVID-19 vaccine administration. The facility census was 57. Findings Include:Review of the medical record of Resident #55 revealed an admission date of 08/05/25. Diagnoses included nondisplaced lateral mass fracture of first cervical vertebra, subsequent encounter for fracture with delayed healing, muscle weakness, unspecified dementia, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 had moderate problems with thinking and memory. [...]

Inspectors wroteBased on observation, resident and staff interviews, medical record review, and review of facility policy, the facility failed to ensure call lights were functional. This affected one (#12) of three residents reviewed for call lights. The facility census was 57.

Inspectors wroteBased on review of the medical record, observations, staff interviews and policy review, the facility failed to ensure Coronavirus-19 (COVID-19) precautions were implemented appropriately for all positive residents. This had the potential to affect all 58 residents residing in the facility. The facility census was 58.

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to ensure laboratory (lab) values were completed as ordered by the physician. This affected two (#01 and #44) out of three residents reviewed for labs being completed as ordered by the physician. The facility census was 58.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to failed to suspend staff pending an abuse investigation. This affected one (Resident #41) of three residents reviewed for abuse. The facility census was 50.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure proper infection control measures were maintained during resident care. This affected two (#37 and #41) residents reviewed for incontinence care. The facility census was 50.

Inspectors wroteBased on closed medical record review, review of the transportation service report, staff interviews, physician interview, and review of the facility policy regarding change in a resident's condition, the facility failed to timely notify the physician of a significant change of condition for one resident (#55). This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death when Resident #55 experienced abnormally low blood pressures over the course of four hours with no notification to the physician of the abnormal levels until Resident #55 was found unresponsive on [DATE] at 5:45 A.M. and subsequently expiring at the hospital later that evening. This affected one (#55) of four residents reviewed for a change in condition. The facility census was 57 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a registered nurse staffed at least eight hours a day, seven days a week. This had the potential to affect all residents residing at the facility. The facility census was 57. Review of staffing tool on 08/10/22 revealed the absence of a registered nurse scheduled on 08/07/22. During interview on 08/10/22 at 12:43 P.M., the Director of Nursing stated there was not a registered nurse in the building on 08/07/22. She stated there was a call off and the facility had contacted an agency to send a nurse and failed to specify the need for a registered nurse. During interview on 08/11/22 at 10:07 A.M., the Executive Director denied the facility having any waivers.

Inspectors wroteBased on record review, staff interviews, and facility policy, the facility failed to monitor resident weight losses and address changes in nutritional status within a timely manner. This affected four residents (#05, #09, #20, and #52) out of four sampled residents. The facility census was 57.

Inspectors wroteBased on observation, record review and facility staff interview, the facility failed to maintain separation of clean and soiled linen. This had the potential to affect all 50 residents who reside in the facility.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure fall interventions were in place. This affected on (#18) of four residents reviewed for accidents. The facility census was 50.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure medication administration error rate was five percent (%) or below. 26 medication opportunities were observed with two errors for an error rate of 7.69%. This affected two (#4 and #23) of four residents observed for medication administration. The facility census was 50.