Deficiency Records for The Cottage Extended Care
Updated as of November 01, 2021
This is not the most recent data for The Cottage Extended Care. For the most recent information, click here.
A list of the most recent deficiencies for The Cottage Extended Care. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-05-21 | 2020-05-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-05-21 | 2020-05-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-11-07 | 2019-11-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-07 | 2019-11-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-29 | 2019-09-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-04-29 | 2019-09-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-29 | 2019-09-09 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-08-28 | 2019-09-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-08-28 | 2019-09-09 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-28 | 2019-09-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-28 | 2019-09-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-28 | 2019-09-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-28 | 2019-09-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-28 | 2019-09-09 | 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 | 2019-08-28 | 2019-09-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-28 | 2019-09-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-07-03 | 2019-09-09 | 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 | 2019-07-03 | 2019-09-09 | 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 | 2019-07-03 | 2019-07-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-29 | 2019-05-29 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-04-29 | 2019-05-29 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2019-04-29 | 2019-05-29 | 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 | 2019-04-29 | 2019-05-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-23 | 2019-05-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-04-23 | 2019-05-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-23 | 2019-05-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-23 | 2019-05-29 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-08 | 2019-04-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-12 | 2019-04-12 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-03-01 | 2018-05-01 | 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 | 2018-03-01 | 2018-05-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-03-01 | 2018-05-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-01 | 2018-05-01 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-03-01 | 2018-05-01 | 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 | 2018-03-01 | 2018-05-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-01 | 2018-05-01 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-02-22 | 2018-04-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-02-22 | 2018-04-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-02-22 | 2018-04-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-02-22 | 2018-04-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-02-22 | 2018-04-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-02-22 | 2018-04-10 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-11-14 | 2016-11-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2016-11-09 | 2016-11-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2016-11-09 | 2016-11-30 | N |
