Cottage Crest Post Acute

In the surveyor’s words

From the most serious findings on record at Cottage Crest Post Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF759Jun 11, 2024

  Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Twenty medication errors out of total 41 opportunities contributed to an overall medication error rate of 48.78 % affecting five of five residents observed for medication administration (Residents 19, 26, 209, 210, and 211.) The medication errors noted were as follows: 1. Omitted administration of Metoprolol Tartrate (a medication used to treat high blood pressure) 75 milligrams ([mg] a unit of measure for weight) to Resident 26. 2. […]

• Immediate jeopardy, isolatedF689Oct 9, 2023

  Based on observation, interview and record review, the facility failed to evaluate and supervise one of four residents (Resident 4) when drug paraphernalia (equipment to use drugs) was found in Resident 4's room. The facility failed to: 1. Ensure Resident 4 was prevented from procuring (an effort of getting something) and using illicit (addictive and illegal) drugs while at the facility by monitoring and supervision of Resident 4. 2. Ensure staff assessed, monitored, and educated Resident 4 about adverse interaction and adverse effects of amphetamine (central nervous system stimulant that causes hypertension, increased heart rate with increased feelings of energy) and other illicit drugs. 3. […]

• Actual harm, isolatedF758Jun 11, 2024

  A.Based on interview and record review, the facility failed to ensure psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) were not used unnecessarily for two of five sampled residents (Resident 22, and Resident 6) by: A1. Failing to ensure one of two sampled residents (Resident 22) did not receive routine and as needed psychotropic drugs unless the medication was necessary to treat a diagnosed specific condition that was documented in the clinical record for Resident 22. A2. Failing to ensure one of two sampled residents (Resident 6) did not receive routine and as needed psychotropic drugs unless the medication was necessary to treat a diagnosed specific condition that was documented in the clinical record for Resident 6. […]

• Actual harm, isolatedF580Jan 19, 2024

  Based on interview and record review, the facility failed to contact and notify the hospice agency (health care service that focuses on the care, comfort, and quality of life of a person with serious illness who is approaching the end of life) that one of five sampled residents (Resident 1) had missed dialysis treatments (mechanical process of removing waste products and toxins, and excess fluid from the body) on [DATE], [DATE], [DATE] and [DATE] due to issues with transportation from the facility to the dialysis center. This deficient practice resulted in Resident 1 being sent out via 911 (emergency medical transport) to a general acute care hospital (GACH) for emergency dialysis on [DATE]. Resident 1 ultimately expired (died ) at 9:32 p.m. […]

• Actual harm, isolatedF698Jan 19, 2024

  Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) received dialysis (process of mechanically removing waste products/ toxins and excess fluid from the body) according to the physician ' s orders and plan of care for dialysis management by failing to: 1. Ensure Resident 1 did not miss three scheduled dialysis treatments ([DATE], [DATE], and [DATE]) and one make-up dialysis treatment ([DATE]). 2. Notify the hospice (health care service that focuses on the care, comfort, and quality of life of a person with serious illness who is approaching the end of life) agency overseeing Resident 1 ' s care while in the facility when Resident 1 missed his first dialysis treatment in the facility ([DATE]). […]