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Deficiency Records for Cottage Crest Post Acute
A list of the most recent deficiencies for Cottage Crest Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Cottage Crest Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-06-11 | 2024-07-08 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-06-11 | 2024-07-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-06-11 | 2024-07-08 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-06-11 | 2024-07-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-06-11 | 2024-07-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-11 | 2024-07-08 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-06-11 | 2024-07-08 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-06-11 | 2024-07-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-06-11 | 2024-07-08 | N |
| 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. | Health | 2024-06-11 | 2024-07-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-06-11 | 2024-07-08 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-06-11 | 2024-07-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-11 | 2024-07-08 | N |
| Dispose of garbage and refuse properly. | Health | 2024-06-11 | 2024-07-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-06-11 | 2024-07-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-06-11 | 2024-07-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-06-11 | 2024-07-08 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-06-11 | 2024-07-08 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-06-07 | 2024-07-04 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-06-07 | 2024-07-04 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-06-07 | 2024-07-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-06-07 | 2024-07-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-07 | 2024-07-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-06-07 | 2024-07-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-06-07 | 2024-07-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-06-07 | 2024-07-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-19 | 2024-02-09 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-01-19 | 2024-02-09 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-01-09 | 2024-01-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-15 | 2024-01-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-06 | 2023-11-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-19 | 2023-11-10 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-19 | 2023-11-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-09 | 2023-11-01 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-08-15 | 2023-09-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-15 | 2023-09-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-17 | 2023-09-01 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-08-17 | 2023-09-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-12 | 2023-08-12 | Y |
| 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. | Health | 2023-07-12 | 2023-08-12 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-06-29 | 2023-07-29 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-06-29 | 2023-07-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-06-29 | 2023-07-29 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-06-29 | 2023-07-29 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-06-29 | 2023-07-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-29 | 2023-07-29 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-06-29 | 2023-07-29 | N |
| Post nurse staffing information every day. | Health | 2023-06-29 | 2023-07-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-29 | 2023-07-29 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-29 | 2023-07-29 | N |
| 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. | Health | 2023-06-29 | 2023-07-29 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-06-29 | 2023-07-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-29 | 2023-07-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-29 | 2023-07-29 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-06-29 | 2023-07-29 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-06-29 | 2023-07-29 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-06-27 | 2023-07-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-27 | 2023-07-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-27 | 2023-07-21 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-06-27 | 2023-07-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-27 | 2023-07-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-06-27 | 2023-07-21 | N |
| 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. | Health | 2023-04-18 | 2023-05-13 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-14 | 2023-04-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-25 | 2022-11-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-29 | 2022-09-20 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-08-25 | 2022-08-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-03 | 2022-07-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-03 | 2022-07-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-23 | 2022-04-11 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-23 | 2022-04-11 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-03-23 | 2022-04-11 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-03-13 | 2020-04-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-03-13 | 2020-04-30 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-03-13 | 2020-04-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-03-13 | 2020-04-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-03-13 | 2020-04-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-03-13 | 2020-04-30 | N |
| Provide activities to meet all resident's needs. | Health | 2020-03-13 | 2020-04-30 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-03-13 | 2020-04-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-03-13 | 2020-04-30 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2020-03-13 | 2020-04-30 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-03-13 | 2020-04-30 | N |
| Post nurse staffing information every day. | Health | 2020-03-13 | 2020-04-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-03-13 | 2020-04-30 | N |
| 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. | Health | 2020-03-13 | 2020-04-30 | N |
| Provide or obtain dental services for each resident. | Health | 2020-03-13 | 2020-04-30 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2020-03-13 | 2020-04-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-13 | 2020-04-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-13 | 2020-04-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-03-13 | 2020-04-30 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2020-03-13 | 2020-04-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-03-18 | 2020-04-14 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2020-03-18 | 2020-04-14 | N |
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