Deficiency Records for Cottage Crest Post Acute
Updated as of October 01, 2022
This is not the most recent data for Cottage Crest Post Acute. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-18 | 2021-08-18 | Y |
| 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 | 2021-08-18 | 2021-08-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-05 | 2021-07-27 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-06-24 | 2021-07-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-24 | 2021-07-06 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2020-07-30 | 2020-09-04 | 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 | 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 |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-03-13 | 2020-04-30 | Y |
| 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 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-06 | 2019-04-29 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-04-06 | 2019-04-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-06 | 2019-04-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-04-06 | 2019-04-29 | 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 | 2019-04-06 | 2019-04-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-04-06 | 2019-04-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-04-06 | 2019-04-29 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-04-06 | 2019-04-29 | 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 | 2019-04-06 | 2019-04-29 | 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 | 2019-04-06 | 2019-04-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-06 | 2019-04-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-06 | 2019-04-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-04-06 | 2019-04-29 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-04-06 | 2019-04-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-05 | 2019-04-29 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-04-21 | 2018-06-01 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-04-21 | 2018-06-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-21 | 2018-06-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-04-21 | 2018-06-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-04-22 | 2018-05-16 | 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 | 2018-04-22 | 2018-05-16 | N |
| 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. | Health | 2018-04-22 | 2018-05-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-22 | 2018-05-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-04-22 | 2018-05-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-04-22 | 2018-05-16 | 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 | 2018-04-22 | 2018-05-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-04-22 | 2018-05-16 | 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 | 2018-04-22 | 2018-05-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-04-22 | 2018-05-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-04-22 | 2018-05-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-04-22 | 2018-05-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-04-22 | 2018-05-16 | 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 | 2018-04-22 | 2018-05-16 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-04-22 | 2018-05-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-22 | 2018-05-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-04-22 | 2018-05-16 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-04-22 | 2018-05-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-22 | 2018-05-16 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-04-22 | 2018-05-16 | N |
