Cottingham Retirement Community

In the surveyor’s words

From the most serious findings on record at Cottingham Retirement Community, in the surveyor’s own words.

• Immediate jeopardy, isolatedF700Aug 25, 2026

  Based on medical record review, observation, staff interview, review of Self-Reported Incident (SRI) reports, review of the United States (US) Food and Drug Administration (FDA) Guide to Bed Safety: Bed Rails in Hospitals, Nursing Homes and Home Healthcare, review of the suffocation and strangulation hazard tag on bed rail, review of bed rail safety warning and assembly instructions, and policy review, the facility failed to thoroughly assess residents for the risk of entrapment and appropriateness for the use of bedrails. This resulted in Immediate Jeopardy and death for Resident #1 when the resident was found unresponsive and without vital signs with his head and neck through the opening of the bedrail on the left side of his bed. […]

• Immediate jeopardy, isolatedF580Aug 19, 2022

  Based on closed medical record review, review of the transportation service report, staff interviews, physician interview, and review of the facility policy regarding change in a resident's condition, the facility failed to timely notify the physician of a significant change of condition for one resident (#55). This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death when Resident #55 experienced abnormally low blood pressures over the course of four hours with no notification to the physician of the abnormal levels until Resident #55 was found unresponsive on [DATE] at 5:45 A.M. and subsequently expiring at the hospital later that evening. This affected one (#55) of four residents reviewed for a change in condition. […]

• Actual harm, isolatedF689Jan 19, 2023

  Based on record review, review of hospital records, staff interview, and review of facility policy, the facility failed to assess residents for fall risk factors and failed to conduct a thorough investigation to determine root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate a fall with injury. This resulted in Actual Harm when Resident #52 was not assessed for risk factors for falls, the resident had a fall on 12/25/22 which was not investigated, and the resident subsequently sustained a laceration to her head from the fall which required transportation to the emergency room for evaluation and treatment including suturing of a head injury. […]

• Actual harm, isolatedF760May 19, 2022

  Based on medical record review, review of hospital records, staff, physician and pharmacist interview, policy review and review of online medication information from Medscape, the facility failed to ensure a cardiac medication was administered per physician orders resulting in a significant medication error. This resulted in Actual Harm when staff administered two like cardiac medications ([MEDICATION(S)] and [MEDICATION(S)]) and the resident was subsequently admitted to the hospital related to a hypotensive episode (low blood pressure) and [CONDITION(S)] (low pulse rate). This affected one (#56) of three residents reviewed for medication administration. The facility census was 56. […]

• No harm, potential for more than minimal, widespreadF812Feb 12, 2026

  Based on observation, review of the freezer and refrigerator temperature logs, interview, and policy review, the facility failed to ensure food was stored and prepared under sanitary conditions. This had the potential to affect 56 out of 56 residents who eat food prepared in the kitchen. The facility identified one (Resident #08) who did not eat food by mouth. The facility census was 57.Findings Included:Observation of the dry food storage area on 02/09/26 at 6:33 P.M. revealed a package of opened, undated sandwich buns with mold growing on one of the buns. In addition, there was an opened, undated loaf of white bread. The Dietary Supervisor #132 verified the above items and discarded them.Observation of the walk-in refrigerator in the main kitchen on 02/09/26 at 6:44 P.M. […]