The December 22 observation came two weeks after the outbreak began, as federal inspectors documented multiple staff members ignoring basic infection control protocols while caring for residents who had tested positive for coronavirus.
Registered Nurse #30 entered Resident #26's room at 8:06 A.M. to administer medications without proper protective equipment. When questioned three minutes later, she confirmed the resident was COVID-positive and acknowledged she hadn't worn the required gear.
The pattern continued throughout the morning shift.
Certified Nursing Assistant #10 delivered breakfast trays to two COVID-positive residents while wearing only a surgical mask. At 8:28 A.M., he entered Resident #13's room without a gown, gloves, N-95 or face shield. Four minutes later, he repeated the violation in Resident #6's room.
"He forgot about it," according to the inspection report, when asked why he failed to follow protocols for the COVID-positive resident.
Another nursing assistant was found in Resident #21's room at 8:43 A.M., again wearing only a surgical mask while caring for a COVID-positive resident. CNA #11 confirmed to inspectors she hadn't worn any of the required protective equipment.
The violations extended to shared rooms. Licensed Practical Nurse #20 entered a room at 8:49 A.M. to give medications to Resident #5, whose roommate had tested positive for COVID-19. The nurse wore only a surgical mask, skipping the gown, gloves, N-95 and face shield required for any room housing a COVID-positive resident.
The outbreak began December 8 and affected 24 of the facility's 58 residents. Contact and droplet precaution signs posted throughout the facility clearly specified the required protective equipment: gown, gloves, N-95 respirator and face shield.
The facility's own policy, updated in September, required healthcare personnel to wear "appropriate PPE in the room (gown, gloves, eye protection, and respirator" when caring for COVID-positive residents. The policy also instructed staff to monitor themselves for symptoms and stay home if ill or testing positive.
Federal inspectors observed the violations during a single morning, suggesting the failures were routine rather than isolated incidents. Each staff member questioned confirmed they knew the residents were COVID-positive but had chosen to skip the required protective equipment.
The systematic breakdown occurred more than five years into the pandemic, when infection control protocols for COVID-19 were well-established and widely understood. The facility housed a vulnerable population of elderly residents, who face higher risks of severe illness and death from coronavirus infections.
Inspectors found the violations affected the potential safety of all 58 residents in the facility. The December 29 inspection was conducted in response to a complaint, though the specific nature of that complaint was not detailed in the report.
The registered nurse, two certified nursing assistants and licensed practical nurse all worked different areas of the facility during the observed shift, indicating the protective equipment failures weren't limited to a single unit or supervisor.
Cottingham Retirement Community's infection control breakdown came as the facility managed an active outbreak affecting nearly half its resident population. The 24 confirmed cases represented a significant portion of the 58-bed facility's census.
The inspection found the facility failed to implement coronavirus precautions appropriately for all positive residents, creating potential exposure risks that extended beyond the immediate patients to include other residents, staff and visitors throughout the building.
Federal regulations require nursing homes to maintain comprehensive infection prevention and control programs, particularly during disease outbreaks. The December violations demonstrated a facility-wide failure to follow established protocols during a critical period when proper precautions were essential to prevent further spread.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cottingham Retirement Community from 2025-12-29 including all violations, facility responses, and corrective action plans.
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