A list of the most recent deficiencies for Cottesmore of Life 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? |
|---|---|---|---|---|
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-26 | 2023-11-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-30 | 2023-09-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-30 | 2023-09-30 | Y |
| 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 | 2023-06-21 | 2023-07-12 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-01-11 | 2023-02-14 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-01-11 | 2023-02-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-01-11 | 2023-02-14 | 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 | 2023-01-11 | 2023-02-14 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-01-11 | 2023-02-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-11 | 2023-02-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-01-11 | 2023-02-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-11 | 2023-02-14 | 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 | 2023-01-11 | 2023-02-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-11 | 2023-02-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-11 | 2023-02-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-11 | 2023-02-14 | N |
| 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 | 2023-01-11 | 2023-02-14 | N |
| Post nurse staffing information every day. | Health | 2023-01-11 | 2023-02-14 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-01-11 | 2023-02-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-01-11 | 2023-02-14 | 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 | 2023-01-11 | 2023-02-14 | N |
| Provide or obtain dental services for each resident. | Health | 2023-01-11 | 2023-02-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-11 | 2023-02-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-11 | 2023-02-14 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-01-05 | 2023-01-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-05 | 2023-01-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-05 | 2023-01-19 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-01-05 | 2023-01-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-05 | 2023-01-19 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-01-05 | 2023-01-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-21 | 2022-12-16 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-08-11 | 2022-09-09 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-06-10 | 2021-08-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-10 | 2021-08-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-10 | 2021-08-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-10 | 2021-08-12 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-06-11 | 2021-07-23 | 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 | 2021-06-11 | 2021-07-23 | 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 | 2021-06-11 | 2021-07-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-06-11 | 2021-07-23 | 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 | 2021-06-11 | 2021-07-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-11 | 2021-07-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-11 | 2021-07-23 | 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 | 2021-06-11 | 2021-07-23 | N |
| 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 | 2021-06-11 | 2021-07-23 | N |
| Post nurse staffing information every day. | Health | 2021-06-11 | 2021-07-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-06-11 | 2021-07-23 | 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 | 2021-06-11 | 2021-07-23 | 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 | 2021-06-11 | 2021-07-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-11 | 2021-07-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-11 | 2021-07-23 | N |
| Respond appropriately to all alleged violations. | Health | 2021-06-11 | 2021-07-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-11 | 2021-07-23 | Y |
| Install proper backup exit lighting. | Fire Safety | 2021-06-10 | 2021-07-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-06-10 | 2021-07-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-10 | 2021-07-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-06-10 | 2021-07-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-06-10 | 2021-07-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-10 | 2021-07-15 | N |
| Enure that solid fuel-burning fireplaces are not in patient sleeping areas. | Fire Safety | 2021-06-10 | 2021-07-15 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2021-06-10 | 2021-07-15 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2021-06-10 | 2021-07-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-10 | 2021-07-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-10 | 2021-07-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-06-10 | 2021-07-15 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-06-10 | 2021-07-15 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-02-22 | 2019-03-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-02-22 | 2019-03-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-22 | 2019-03-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-02-22 | 2019-03-18 | 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 | 2019-02-22 | 2019-03-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-22 | 2019-03-18 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-02-21 | 2019-03-15 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-02-21 | 2019-03-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-02-21 | 2019-03-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-02-21 | 2019-03-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-21 | 2019-03-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-21 | 2019-03-15 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2019-02-21 | 2019-03-15 | N |
