Cottesmore of Life Care

In the surveyor’s words

From the most serious findings on record at Cottesmore of Life Care, in the surveyor’s own words.

• Actual harm, isolatedF760Aug 18, 2025

  Based on interview and record review, the facility failed to ensure residents were administered their ordered anticoagulation (blood thinner-to reduce the risk of the formation of blood clots) medication for 3 of 15 sampled residents (Resident 1, 2, and 3) reviewed for significant medication errors. Resident 3 experienced harm when they did not receive anticoagulation medication as ordered for 17 days due to a medication reconciliation error and had a decline in condition that included signs and symptoms of a stroke (a medical condition that occurs when blood flow to the brain is interrupted or reduced, leading to brain tissue damage) that required transport to the emergency room (ER) for evaluation and treatment. […]

• Actual harm, isolatedF686Oct 26, 2023

  Based on interview and record review, the facility failed to provide care and services according to professional standards of practice to prevent pressure injury for 1 of 3 residents (Resident 1) reviewed for pressure injuries. Resident 1 experienced harm when the facility failed to monitor the integrity of Resident 1's skin under a removable leg/knee immobilizer brace which developed into a lower leg pressure injury that was unstageable and contained dead tissue in the wound bed. Findings included . […]

• Actual harm, isolatedF689Jun 11, 2021

  Based on observation, interview and record review the facility failed to ensure resident environments were free from accident hazards for two of 10 residents (Resident 278 and 1) reviewed for falls and accidents. Failure to assess identified risk factors and ensure adequate supervision resulted in actual harm for Resident 278 when the resident had multiple falls and sustained a fracture. In addition, the facility failed to identify, assess, obtain an order and care plan for an assistive/enabling device for Resident 1, and placed that resident at risk of avoidable injuries and a diminished quality of life. […]

• No harm, potential for more than minimal, widespreadF812Jan 13, 2025

  Based on observation, interview, and record review, the facility failed to prepare and store food in a sanitary manner in the main kitchen and 3 of 3 resident refrigerators (West, East, and Transitional Care Unit) when reviewed for kitchen. This failure placed residents at risk of consuming expired or spoiled food, foodborne illness, avoidable discomfort, and a diminished quality of life. Findings included . Observation on [DATE] at 9:10 AM to 9:26 AM of the kitchen showed the following: 1) Two freestanding refrigerators with temperature logs missing 5 of 13 temperatures. 2) One freestanding refrigerator with opened and undated whipped frosting. 3) Three plates of cooked and plated breakfast meal plates on the shelf above the steamtable without temperature controls. […]

• No harm, potential for more than minimal, patternF692Feb 27, 2026

  Based on observation, interview, and record review, the facility failed to ensure residents' with fluid restrictions had fluid intake monitoring to avoid fluid overload for 3 of 3 sampled residents (Residents 94, 100, and 111) when reviewed for nutrition. This failure placed residents at risk of fluid overload, avoidable discomfort, and a diminished quality of life. Findings included .Resident 94 Review of the electronic health record (EHR) showed Resident 94 admitted to the facility on [DATE] with diagnoses to include heart failure, right ankle pain and dysphagia (difficulty swallowing). Resident 94 was able to make needs known. […]