NORWALK, CA - Federal inspectors documented severe medication administration failures and infection control breaches at Cottage Crest Post Acute during a June 2024 inspection, identifying a 48.78% medication error rate and multiple violations of basic hygiene protocols that placed residents at increased risk of infection and medical complications.
Widespread Medication Administration Failures
Inspectors observed Licensed Vocational Nurse 1 (LVN 1) administering medications to five residents over the course of several hours, documenting critical failures in basic infection control practices. During a medication pass beginning at 8:47 a.m. on June 4, 2024, LVN 1 failed to disinfect the medication tray or cart counter before or after preparing medications for Resident 26, who required treatment for end stage renal disease and cardiovascular conditions.
The pattern continued throughout the morning. At 9:10 a.m., while administering medications to Resident 209—a patient with chronic heart failure and atrial fibrillation—LVN 1 disinfected the blood pressure cuff but failed to clean the medication preparation surfaces. At 9:45 a.m., the nurse entered Resident 211's room, which was posted with Enhanced Precautions requiring gloves and gown for high-contact care. LVN 1 wore a gown but no gloves while taking the resident's blood pressure and administering medications.
The inspection revealed that out of 41 total opportunities observed, facility staff failed to administer 20 medications according to physician orders or professional standards. This failure rate affected multiple residents and involved various types of medications, including those managing serious cardiac and infectious disease conditions.
During a June 8, 2024 observation, LVN 5 administered medication through a gastrostomy tube to Resident 47 without performing hand hygiene before or after the procedure. When questioned, LVN 5 acknowledged typically washing hands only at the end of medication administration rounds rather than between patients. The nurse acknowledged understanding that residents with gastrostomy tubes face heightened infection risk due to the surgical opening into the stomach, yet failed to follow basic hygiene protocols.
Critical Hand Hygiene Violations
The facility's infection control failures extended beyond medication administration. On June 4, 2024, at 11:16 a.m., inspectors observed Certified Nursing Assistant 1 (CNA 1) providing hygiene care and repositioning for Resident 31, a patient with documented extended spectrum beta lactamase resistance and immunodeficiency. CNA 1 removed gloves after exiting the room and touched the trash lid without sanitizing her hands. She then walked to the therapy room to request assistance and re-entered Resident 31's room without performing hand hygiene before putting on new gloves.
After completing care, CNA 1 again removed her gloves, lifted the trash lid barehanded, and walked toward the nursing station without hand hygiene. When questioned by inspectors, CNA 1 acknowledged she should have washed or sanitized her hands before entering the resident's room and after providing care to prevent spreading infections among vulnerable residents.
The infection control breaches became more concerning when staff provided care to residents under Enhanced Barrier Precautions. On June 5, 2024, at 7:35 a.m., inspectors observed CNA 2 and CNA 3 in a room shared by Resident 6 (on Enhanced Precautions) and Resident 211 (not on precautions). When Resident 211 pressed the call light requesting repositioning, CNA 2 entered without washing hands or wearing gloves, while CNA 3 entered wearing appropriate protective equipment.
After repositioning Resident 211, both nursing assistants responded to Resident 6's request to be turned. CNA 2 removed her gloves and sanitized her hands, but then touched Resident 6 without putting on new gloves, despite the posted Enhanced Precautions requiring gown and glove use. CNA 2's uniform contacted Resident 6's blanket. When Resident 211 subsequently asked CNA 2 to adjust her blanket, CNA 2 removed her gloves and handled the blanket without washing hands between residents.
Medical Significance of Infection Control Failures
Proper hand hygiene represents the single most effective intervention for preventing healthcare-associated infections. The Centers for Disease Control and Prevention identifies hand hygiene compliance as fundamental to infection prevention because hands serve as the primary vector for transmitting pathogens between patients, healthcare workers, and environmental surfaces.
When healthcare workers fail to perform hand hygiene between patient contacts, they create direct pathways for bacterial and viral transmission. This risk intensifies dramatically for residents with compromised immune systems, surgical sites, or medical devices that breach normal skin barriers. Residents with gastrostomy tubes face particular vulnerability because the tube creates a direct pathway from the external environment into the sterile gastrointestinal tract.
Enhanced Barrier Precautions exist specifically to protect against transmission of multidrug-resistant organisms—bacteria that have developed resistance to multiple antibiotics, making infections extremely difficult to treat. When staff fail to wear appropriate protective equipment during high-contact care activities for residents on Enhanced Precautions, they risk spreading these dangerous organisms to other residents who may lack any effective treatment options if infected.
The medication administration environment requires particular attention to infection control because contamination of medication carts, trays, or supplies can affect multiple residents. When nurses fail to disinfect preparation surfaces between residents, any pathogens present can contaminate medications, leading to infection transmission through an entirely preventable route.
Food Safety and Sanitation Violations
Beyond medication and infection control failures, inspectors identified multiple food safety violations that placed residents at risk of foodborne illness. During a June 4, 2024 inspection of kitchen refrigerators at 8:26 a.m., inspectors observed cilantro dated May 29, 2024—five days beyond the facility's one-week freshness standard—visibly yellowing and deteriorating. Additional produce including avocado, ginger, yellow pepper, and lemon had no date labels whatsoever.
In the dry pantry, inspectors found Tabasco sauce expired in January 2024, almond extract expired in September 2022, and six unopened containers of instant coffee grounds expired in February 2024. The Dietary Manager stated the facility no longer used instant coffee, yet the expired product remained in food storage areas for months.
Food storage violations extended to improper organization that created cross-contamination risks. Inspectors observed raw sausages stored on the same shelf as fruits, with cured meat stored on a lower shelf. The Dietary Manager acknowledged that raw meat should be stored on the bottom shelf to prevent juices from contaminating other foods, but stated she "did not mind if the meat is touching other items" as long as packaging remained sealed—a statement contradicting basic food safety principles that packaging can fail or leak.
Kitchen staff demonstrated additional hygiene failures. On June 4, 2024, at 10:39 a.m., Dietary Aide 2 removed gloves and left the kitchen without performing hand hygiene. Upon returning at 10:30 a.m., the dietary aide put on new gloves and began cleaning trays without washing hands despite entering from outside the kitchen environment.
Pneumonia Vaccination Failure
The facility failed to ensure Resident 47 received pneumococcal vaccination despite multiple physician orders dating to May 2023. Resident 47's medical record documented physician orders for pneumonia vaccine on May 9, 2023, June 28, 2023, and May 31, 2024. Despite these repeated orders, the resident did not receive vaccination until June 7, 2024—the day inspectors questioned staff about the missing immunization.
The consequences of this failure materialized when Resident 47 developed right lower lobe aspiration pneumonia in September 2023, requiring hospitalization. The resident returned to the facility on October 5, 2023, but still received no pneumonia vaccination. In May 2024, chest x-ray revealed right upper lobe pneumonia, requiring antibiotic treatment with Levaquin beginning May 7, 2024.
Resident 47's documented medical conditions created multiple risk factors for pneumonia, including gastrostomy tube feeding, immobility, cerebrovascular accident history, and dysphagia. The Infection Prevention Nurse acknowledged that residents without pneumonia vaccination face elevated risks for developing this serious respiratory infection, particularly when multiple risk factors exist. The pneumococcal vaccine provides protection against the most common bacterial causes of pneumonia in adults, making vaccination especially important for residents with complex medical conditions.
Systemic Quality Assurance Failures
Perhaps most concerning, facility leadership failed to identify or address these deficiencies through internal quality assurance processes. During a June 11, 2024 interview, the Administrator acknowledged being unaware of medication administration problems and staffing shortages until inspectors identified them during the survey. The Administrator stated he would discuss these issues in the June Quality Assurance Performance Improvement meeting, acknowledging the committee had failed to implement effective plans despite similar deficiencies identified in previous surveys.
The facility's quality assurance process failed to track medication errors despite policy requirements for routine monitoring. Staff did not conduct investigations into identified medical errors to analyze underlying causes, nor did they develop corrective action plans to prevent recurrence. The Administrator acknowledged failing to include direct care staff who work on the floor in quality assurance meetings, eliminating the frontline perspective essential for identifying and addressing care delivery problems.
Additional Issues Identified
Inspectors documented inadequate staffing levels, with Certified Nursing Assistant direct care hours falling at or below the 2.4-hour minimum on multiple days between April 15-20, 2024. The facility employed two Restorative Nursing Assistants, but both were unavailable during this period, resulting in 28 residents not receiving prescribed restorative nursing services. Despite having a contract with a staffing registry agency, facility leadership failed to request supplemental staff to maintain required service levels.
Physical plant deficiencies included two large garbage dumpsters overflowing with lids unable to close, plus two additional carts containing disposable items with no covers. Uncovered waste containers create conditions attracting insects and rodents that can compromise kitchen sanitation and increase infection risks. The facility's room waiver had expired, with 33 multi-bed rooms measuring less than the required 80 square feet per resident, though inspectors noted adequate space for resident movement and care delivery during the survey period.
The inspection findings at Cottage Crest Post Acute reveal systemic failures across multiple domains of basic nursing home care—medication administration, infection control, food safety, preventive health services, and quality oversight. These violations demonstrate how breakdowns in fundamental care processes can create compounding risks for vulnerable residents requiring skilled nursing services.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cottage Crest Post Acute from 2024-06-11 including all violations, facility responses, and corrective action plans.
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