Cottingham Care Community

Based on medical record review, resident and staff interview, and policy review, the facility failed to ensure medications were administered as ordered. This affected one (#89) of three residents sampled for medication administration. The facility census was 99.

Findings include:

Review of the medical record revealed Resident #89 was admitted to the facility on 06/15/23 with diagnoses of depression, mild neurocognitive disorder, unspecified dementia, bipolar disorder, hypertension and anxiety.

Review of the Assisted Living Service/Functional Assessment dated 07/10/25 revealed Resident #89 required reminders for ambulation, fall prevention and bathing, and was independent for eating, toileting, dressing and grooming.

Review of physician orders for Resident #89 revealed an order dated 02/04/25 for Ativan, 0.5 mg, give one tablet by mouth two times a day related to anxiety disorder and Ativan 0.5 mg, give on tablet by mouth every 24 hours as needed for anxiety disorder.

Review of the Medication Administration Record (MAR) for 07/25 for Resident #89 revealed Ativan 0.5 milligram (mg), give one tablet by mouth two times a day was not administered on 07/04/25 at 8:00 P.M., on 07/05/25 at 8:00 A.M., on 07/06/25 at 8:00 A.M. and 8:00 P.M., and on 07/07/25 at 8:00 A.M.

Interview on 08/05/25 at 11:52 A.M. with Resident #89 revealed the resident did not receive the Ativan on 07/04/25, 07/05/25 and 07/06/25.

Interview on 08/05/25 at 2:24 P.M. with the Assisted Living Director of Nursing verified Resident #89 did not receive Ativan 0.5 mg by mouth on 07/04/25 at 8:00 P.M., on 07/05/25 at 8:00 A.M., on 07/06/25 at 8:00 A.M. and 8:00 P.M., and on 07/07/25 at 8:00 A.M.

Interview on 08/05/25 at 3:11 P.M. with the Administrator verified Resident #89 did not receive Ativan 0.5 mg by mouth on 07/04/25 at 8:00 P.M., on 07/05/25 at 8:00 A.M., on 07/06/25 at 8:00 A.M. and 8:00 P.M., and on 07/07/25 at 8:00 A.M.

Review of the policy titled, Administration Procedures for All Medications

Based on record review and staff interviews, the facility failed to maintain an incident log with the required information. This had the potential to affect all 93 residents. The census was 93.

Findings include:

Interview on 04/08/25 at 9:47 A.M., with Administrator, during entrance conference, requested initial list of documents needed for survey including incident log. Discussed incident log with the Administrator again on 04/08/25 at 3:36 P.M., who reported information is mostly documented in Point Click Care. Requested access to documentation at that time.

Interview on 04/09/25 at 8:34 A.M.. with the Administrator revealed she has not been able to locate the information requested regarding the incident log but had Assistant Director of Nursing (ADON) #8 looking in her office. The Administrator revealed she found one incident report in her office but believes ADON #8 will be able to locate what they have.

Interview on 04/09/25 at 3:17 P.M., with Administrator and ADON #8 on 04/09/25 at 3:17 P.M. revealed ADON #8 continued to believe it is contained in Point Click Care but does not know the location of the information.

Review on 04/11/25 at 8:54 A.M., revealed the facility provided a copy of the incident log found in Point Click Care from the Administrator. The incident log contained the names of residents involved, dates and times of incident as well as a general description of the incidents but does not include any specific information about each incident nor information regarding care provided, interventions taken to correct or intervene in the situation.

Interview with the Administrator at the time of the review, verified the log did not contain the required information.

Based on observation and staff interview, the facility failed to ensure foods were stored in a manner that protects against contamination and spoilage. This affected all 93 residents who received meals from the kitchen and kitchenettes. The facility census was 93.

Findings include:

Observation on 04/08/25 at 9:46 A.M., of the dry food storage area, revealed an open container of cornstarch dated 03/23/25 which was open to air sitting on a shelf next to several unopened containers of cornstarch. Interview with the Dietary Manager (DM), at the time of the observation, confirmed it should not be open and removed it from the shelf.

Observation on 04/08/25 at 9:48 A.M., of the dry food storage area revealed an open container of maple syrup that had no open date, only a received-on date. Interview with DM, at the time of the observation, confirmed it should have an opened on date on it and removed it from the area.

Observation on 04/08/25 at 9:51 A.M., of the dry food storage area revealed an open bag of confectioner's sugar in a box filled with cake mixes undated and open to air. Interview with DM, at the time of the observation,confirmed was opened and should not have been stored in a box with cake mixes. DM removed the sugar and discarded.

Observation on 04/08/25 at 10:01 A.M., of the walk-in refrigerator revealed an open bag of hard salami with an open date of 02/04/25 and a use by date of 02/10/25. Interview with the Administrator, at the time of the observation, confirmed it was out of date and removed from the refrigerator.

Based on observation and staff interview, the facility failed to provide residents living in the residential care facility with working call systems in their individual rooms. The only call system available was in resident bathrooms. This affected 93 of the 93 residents currently residing in the residential care area. The census was 93

Findings include:

Interview with Administrator on 04/09/25 at 2:30 P.M., revealed she was aware of the pull cord in resident's bathrooms but is not aware of any other call system availability in the residential care facility apartments

Review of Resident #28's medical reocrd revealed she is alert and oriented as well as functionally independent (when using a motorized chair) as indicated on her most recent functional assessment.

Interview abd observation on 04/09/25 at 2:21 P.M., with Resident #28 revealed she has a pullcord call system in her bathroom but Resident #28 revealed there was no other call system available in her apartment.

Review of Resident #55's medical record revealed he does require moderate assist with showers and reminders for other personal care as indicated on his most recent functional assessment.

Interview and observation on 04/09/25 at 2:40 P.M., of Resident #55's apartment reveals a pull cord call system in the bathroom but observation and interview with Resident #55 revealed there is no other call system in his apartment.

Interview on 4/09/25 at 2:53 P.M., with Resident Aide (RA) #2 confirmed residents have only one pull cord call system in their apartments which is located in their bathrooms. RA #2 revealed that there were not any other pull cords or call mechanisms within the residential care apartments.

Based on medical record review, staff interview, and policy review, the facility failed to ensure medications were administered as ordered. This affected one (#34) of five residents sampled for medication administration. The facility census was 91.

Findings include:

Review of the Resident #34's medical record revealed the resident was admitted to the facility on 08/01/24. Diagnoses included bipolar disorder, unspecified anxiety disorder, hypertension, and chronic pain.

Review of the most recent functional assessment dated 11/01/24 revealed Resident #34 was independent and oriented with occasional forgetfulness, needed minimal supervision with activities of daily living (ADLs), had occasional behaviors, did not reject care, and did not wander.

Review of admission paperwork dated 07/18/24 revealed Resident #34 had orders for medications upon admission to the facility on 08/01/24 including the antidepressant duloxetine (Cymbalta) 60 milligrams (mg) by mouth once daily.

Review of Resident #34's medical record revealed no orders for Cymbalta were initiated until 08/04/24 when the resident was ordered Cymbalta by mouth daily.

Review of Resident #34's medication administration record (MAR) for August 2024 revealed the resident received the first administration of Cymbalta on 08/05/2024.

During an interview on 11/08/24 at 12:06 P.M. with Assistant Director of Nursing (ADON) #130 verified Resident #34 had orders for Cymbalta on her admission paperwork, the order was not initiated on admission, and did not receive the medication until 08/05/2024. ADON #130 stated it was an oversight made during reconciliation of the admission.

Review of policy titled, Medication Administration

Based on observation, staff interview, medical record review, and policy review, the facility failed to maintain proper infection control during medication administration. This affected two (#55 and #92) of five residents reviewed for medication administration. The facility census was 91.

Findings include:

1. Review of the medical record revealed Resident #55 was admitted to the facility on 05/20/23. Diagnoses included type I diabetes, unspecified depression, unspecified anxiety disorder, unspecified dementia, and chronic obstructive pulmonary disease.

Review of the most recent functional assessment dated 10/25/24 revealed Resident #55 needed occasional reminders, had no behaviors, did not reject care, and did not wander.

Review of the medical record revealed Resident #55 had current physician orders for aspirin 81 milligrams (mg) by mouth once daily, cetirizine 10 mg by mouth once daily, cholecalciferol 125 micrograms (mcg) by mouth once daily, fluoxetine propionate nasal suspension 50 mg per actuation two sprays in each nostril once daily, hydrochlorothiazide 12.5 mg by mouth once daily, Januvia 100 mg by mouth once daily, levothyroxine 75 mcg by mouth once daily, losartan 25 mg by mouth once daily, memantine-donepezil 24-hour extended release 28-10 mg by mouth once daily, buspirone 15 mg by mouth twice daily, carvedilol 6.25 mg by mouth twice daily, Lexapro 10 mg by mouth twice daily, potassium chloride 20 milliequivalents (mEq) by mouth twice daily, Seroquel 150 mg by mouth twice daily, Symbicort 160-4.5 mcg per actuation inhale two puffs by mouth twice daily, Albuterol Sulfate inhalation aerosol solution 106 mcg per actuation inhale two puffs by mouth three times daily, and Novolog insulin 100 unit per milliliter (ml) inject subcutaneously with meals as per sliding scale all to be administered in the morning.

2. Review of the medical record revealed Resident #92 was admitted to the facility on 07/10/23. Diagnoses included unspecified dementia, peptic ulcer, hypertension, and anemia.

Review of the most recent functional assessment dated 10/10/24 revealed Resident #92 was independent with occasional forgetfulness, had no behaviors, did not reject care, and did not wander.

Review of the medical record revealed Resident #91 had current physician orders including Aricept five (5) mg by mouth once daily, clopidogrel 75 mg by mouth once daily, ferrous sulfate 325 mg by mouth once daily every day except Thursday, folic acid one (1) mg by mouth daily every day except Thursday, Januvia 50 mg by mouth once daily, pravastatin 80 mg by mouth once daily, sertraline 50 mg by mouth once daily, buspirone 10 mg by mouth twice daily, metformin 500 mg by mouth twice daily, and Humalog insulin 100 unit per ml inject subcutaneously as per sliding scale three times daily all to be administered in the morning.

Observation on 11/08/24 from 8:06 A.M. to 8:18 AM revealed Licensed Practical Nurse (LPN) #113 did not sanitize her hands before she prepared morning medications for Resident #55 by pouring medications out of roll packs into a plastic medication cup on the medication cart. One pill landed on the medication cart and LPN #113 picked up the medication with her bare fingers and placed it in the medication cup for administration. LPN #113 administered the medications to the resident, assisted the resident to self-administer nasal spray, monitored blood glucose levels, and signed off medications in the computer. Continued observation at 8:18 A.M. revealed LPN #113 did not sanitize her hands before or after preparing medications, performing blood glucose monitoring, or administering medications to Resident #91

During an interview on 11/08/24 at 8:06 A.M. LPN #113 verified she dropped Resident #55's vitamin D (cholecalciferol 125 mcg) tablet on the medication cart, picked it up with her fingers, and placed the medication in medication cup. Additional interview at 8:23 A.M. with LPN #113 verified she did not perform hand hygiene at all before, during, or after administering medications to Resident #55 and Resident #91. LPN #113 stated she had hand sanitizer in her bag and performed and sanitization every two to three residents during medication administration.

Review of policy titled, Administering Medications

Based on record review and staff interview, the facility failed to ensure two Resident Aides (RA) (#114 and #116) completed their first aide training within the first sixty days of employment. This had the potential to affect all residents at the facility. The facility census was 60.

Findings include:

Review of RA #114's personnel record revealed a hire date of 09/09/22. Further review revealed no documented evidence of any first aide training.

Review of RA #116's personnel record revealed a hire date of 02/17/22. Further review revealed no documented evidence of any first aide training.

Interview on 03/30/23 at 6:11 P.M. with the Administrator verified the facility failed to provide first aide training to RAs #114 and #116

Based on observation, record review, and staff interview, the facility failed to ensure medications were stored properly. This affected one resident (#04) out of three residents observed for medication storage. The facility census was 60.

Findings include:

Medical record review for Resident #04 revealed the resident was admitted to the facility on 01/28/15. Her diagnoses included chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), gout, chronic renal insufficiency, hypothyroidism, hyperlipidemia, and osteoporosis.

Review of the physician's medication assessment dated 04/22/22 revealed Resident #04 was not permitted to keep medications in her room.

Review of the most recent annual health assessment dated 03/17/23 revealed Resident #04 was cognitively intact.

Review of the nursing progress note dated 03/30/23 revealed the writer obtained twenty-seven bottles of over the counter medications, pain cream, heating pad, and pain patches from Resident #04's room.

Observation and interview on 03/30/23 at 10:30 A.M. with Resident #04 revealed she was seated in her recliner chair as she pointed at a large container of over-the-counter Tylenol (pain) 325 milligram (mg) sitting on her windowsill and next to the bottle of Tylenol, was a bottle of over-the-counter medication called, Sleep Aide. Continued observation revealed two large bottles of Hair Skin and Nail vitamins on the floor next to her foot, a large bottle of the over the counter Gaviscon (heart burn relief) on the counter, a box of lidocaine patches, a large bottle of Vitamin C (supplement) , Prevagen (supplement), Nystatin Powder (antifungal), a large bottle of Aspirin (pain), a large container of Tums (antacid), Diclofenac (pain relief) gel, a large bottle of fiber gummies, Laxatives, and Lactaid (digestion aid).

Interview on 03/30/23 at 10:50 A.M. with Licensed Practical Nurse (LPN) #120 confirmed Resident #04 was not permitted to keep medications, including prescription and over the counter medications, in her room. LPN #120 verified the medications being stored in Resident #04's room.

Based on observation, record review, resident interview, and staff interview, the facility failed to ensure a resident's fall with injury was completly and thoroughly investigated. This affected one (Resident #04) out of three residents of reviewed for falls. The facility census was 60.

Findings include

Resident #04 was admitted to the facility on 01/28/15. Her diagnoses included, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), gout, chronic renal insufficiency, hypothyroidism, hyperlipidemia, and osteoporosis.

Review of the most recent annual health assessment dated 03/17/23, revealed Resident #04 was cognitively intact. Further review of the health assessment revealed Resident #04 required limited assistance with medications and needed daily supervision for self administration of medications. Resident #04 was an intermediate level of care.

Review of Resident #04's progress notes dated 01/14/23, revealed Resident Associate (RA) #114 reported to Resident #04 lost balance in the restroom and fell. RA #114 stated she helped the resident up and the resident had normal range of motion (ROM). A follow up note dated 03/09/23, as a late entry for 01/15/23 revealed, RA #114 reported Resident #04 had a fall in her bathroom and that she (RA #114) performed ROM and got her into bed.

Interview on 03/30/23 at 10:30 A.M. with Resident #04 revealed she fell in the bathroom on 01/15/23. Resident #04 stated RA#114 came into her room and stated she would help Resident #04 up off the floor. Resident #04 asked RA #114 to call a code because usually two staff members would help her up. However, RA #114 told Resident #04 she was trained in sports medicine and could help her up. Resident #04 stated RA #114 told her to cross her arms in front of her, and RA #114 attempted to pick her up in a bear hug type transfer. Resident #04 reported both RA #114 and Resident #04 heard her shoulder pop. Resident #04 stated RA #114 helped her back to bed.

Interview on 03/30/23 at 11:38 A.M. with the Wellness Director (WD) #151 confirmed the facility policy regarding a resident that has fallen is the nurse should assess the resident prior to the resident being moved and two staff members should assist the resident off the floor. WD #151 explained she was new to the facilty and did not become aware of the incident until 03/10/23 when Resident #04's case manager quesioned her about the incident. WD #151 was unable to provide any verification of the fall being investigated prior to 03/10/23 .

Interview on 03/30/23 at 2:03 P.M. with Licensed Practical Nurse (LPN) #120 revealed she was the nurse working the night of the Resident #04 fell on 01/15/23. LPN #120 stated RA #114 told her she found Resident #04 on the ground and assessed her range of motion and assisted Resident #04 was back in bed. LPN #120 stated she was new to the assisted living and was not sure what the proper protocol regarding finding a Resident on the floor. However, LPN #120 stated the nurse on duty is supposed to assess the Resident prior to the Resident being removed from the floor. LPN #120 confirmed she did not complete an incident or investigation until she was ask to provide information to WD #151 on 03/10/23.

Interview on 03/30/23 at 4:20 P.M.with RA #114 revealed she was working on the evening of 01/15/23 the night of Resident #04's fall . RA #114 stated she heard Resident #04 yelling for help. RA #114 stated she went to her room and observed Resident #04 on the floor in the bathroom. RA #114 stated she was unable to call for help because the walkie/talkie was not charged and she did not have her cell phone. RA #114 stated after half hour of trying to locate the nurse she attempted to pick Resident #04 off the floor by herself. RA #114 stated she was trained to get the nurse and always utilize two caregivers to move a resident in her orientation. However, at this point she felt it was more important to get Resident #04 off the floor. RA #114 stated Resident #04 told her it usually takes to people to get her off the floor. However, RA #114 told Resident #04, she was trained in sports medicine and could lift Resident #04 off the floor onher own. RA #114 stated she put her arms around Resident #04's crossed arms and attempted to pick Resident #04 off the floor. RA #114 stated as Resident #04 was reaching for her walker they both heard Resident #04's shoulder pop. RA #114 stated she popped Resident #04's arm in place for her.

Interview on 03/30/23 at 6:00 P.M. with the Administrator confirmed RA #114 did not receive the required First Aide Training within sixty days of her hire at the facility.

Interview on 04/10/23 at 3:05 P.M. interview with the former Wellness Director (FWD # 300). FWD #300 confirmed received a text from RA #114 several days after Resident #04 had fell. FWD #300 confirmed she was unable to provide the investigation of the fall on 01/15/23. FWD #300 stated RA #114 stated she popped Resident #04's shoulder back in place and lifted her from the floor alone on 01/15/23. FWD #300 confirmed RA #114 is not qualified to assess a Residents injury or pop a shoulder back in place. FWD #300 confimed the facility did not have an investigation completed of the incident regarding Resident #04 and RA #114.

Review of the facility form titled, Fall/Post Fall Protocol for AL/IL, undated, stated revealed the nurses are required to complete three steps for a fall investigation. The three steps included, 1. Complete Risk Managment, 2. A nurseaction must include resident assessment among several actions, 3. Must complete all documentation within twenty-four hours of the fall.

This violation identified facility non compliance at the time of the complaint survey completed on 04/20/23.

Based on observation and staff interview, the facility failed to ensure foods were stored in a manner that protects it against contamination and spoilage. This affected all 60 residents who received meals from the kitchen and kitchenette. The facility census was 60.

Findings include:

Observation of the kitchenette on 03/30/23 at 7:47 A.M. with Dietary Aide (DA) #156 revealed the refrigerator contained a large plastic container of ham salad dated 02/24/23. The refrigerator also contained a large container of what appeared to be chicken salad with no label and was undated, a container of unidentified lunch meat with no label and undated, and a large container of tomatoes with no label and updated. Additionally, the freezer contained individually dipped containers of what appeared to be ice cream with no label and undated. DA #156 confirmed the unlabeled and undated food items stored in the refrigerator and freezer.

Observation of the large kitchen on 03/30/23 at 7:55 A.M. with DA #157 revealed the walk-in refrigerator contained a large cart of uncovered food that included three large salads with eggs, several dishes of orange slices, and sliced pies in styrofoam containers all unlabeled and undated. The cart of uncovered food also contained several dishes of what appeared to be pudding in individual cups. DA #157 confirmed the foods were unlabeled and undated.