Cottage Crest Post Acute
COTTAGE CREST POST ACUTE in NORWALK, CA — inspection on February 24, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
not called to attend a meeting to discuss Resident 2's care concerns and interventions after her fall
p.m. to 7 a.m.) and the paramedics transferred Resident 2 to the GACH for further treatment. RN 1
informed the Certified Nursing Assistant (CNA unknown) assigned to Resident 2 to perform frequent visual checks to ensure Resident 2's safety. RN 1 stated he was unable to review and revise Resident 2's risk for fall care plan and did not formulate a care plan for an actual fall. RN 1 stated it was the responsibility of the licensed nurses to update and revise the care plan of the residents to prevent another fall.During a concurrent interview and record review on 2/24/2026 at 12:31 p.m. with the Director of Rehab (DOR), Resident 2's Clinical Record was reviewed.
The DOR stated Resident 2 had poor safety awareness and required assistance during transfer and walking because she was unsteady.
The IDT had a meeting after Resident 2's fall on 12/25/2026 to discuss Resident 2's fall precautions and revision of care plan interventions.
The DOR confirmed there was no IDT meeting documented in Resident 2's Clinical Record and Resident 2's risk for falls care plan had not been revised and/or updated.
The DOR stated the IDT should have conducted an interdisciplinary meeting with Resident 2's emergency contacts so the emergency contacts could share recommendations and participate in the planning and/or revising of Resident 2's plan of care.
During an interview and concurrent record review on 2/24/2026 at 3:03 p.m., the DON stated and confirmed Resident 2's risk for falls care plan was not revised and/or updated after Resident 2 had a fall on 12/25/2025.
The DON stated Resident 2's care plans should have been updated and revised by the licensed nurses after Resident 2's fall to reflect the accurate fall precautions and/or interventions to ensure awareness of the nursing staff and to prevent delay of care of Resident 2.During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, revised 12/19/2022, the P&P indicated the facility shall develop, implement and revise a comprehensive person- centered care plan for each resident consistent with resident rights, that includes measurable objectives and timeframes to meet the residents' medical, nursing, mental and psychosocial needs based in the resident's comprehensive assessment.
The residents' comprehensive care plan will be prepared by the facility's interdisciplinary team that includes, but is not limited to:a.
The attending physicianb. A registered nursec. A nurse aided. A member of the nutrition servicese.
The resident and the resident's representativef.
Other staff or professionals involved in care of the residents such as therapists, social workers, activity personnel, family members, administrator, discharge coordinator, mental health professionals and chaplain.During a review of the facility's P&P titled, Fall Prevention Program, revised 12/28/2023, the P&P indicated the facility shall review the residents' care plan and update as indicated.
055758 02/24/2026
Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650
interaction within the community.
The facility shall sponsor group, individual and independent
055758 02/24/2026
Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650
in accordance with accepted professional standards.
interview and record review, the facility failed to ensure Registered Nurse (RN) 1 accurately
body's most basic and life sustaining functions) for one of three sampled residents (Resident 2) when Resident 2 had a change of condition on 12/25/2026 and was transferred to a General Acute Care Hospital via 911 for further evaluation.
This deficient practice had the potential for Resident 2's change of condition to be unrecognized, undetermined, or inadequately identified.
This deficient practice also had the potential to negatively impact Resident 2's health status, interrupt the continuity of care, and impair timely and accurate communication among facility team members and with emergency personnel.
Findings:During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (temporary or permanent damage to the brain due to lack of glucose, oxygen or other metabolic agent, or organ dysfunction), dementia (a progressive state of decline in mental abilities), and difficulty walking.During a review of Resident s's Minimum Data Set ([MDS] a resident assessment tool) dated 7/8/2025, the MDS indicated Resident 2 was not able to make decisions that were reasonable and consistent and required partial/moderate assistance (helper does more than half the effort) from staff to complete her activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing and toileting a person performs daily), such as toilet transfer, repositioning from sitting to standing ,position and transferring from the bed/chair-to- chair.
The MDS indicated Resident 2 was incontinent of bowel and bladder (involuntary voiding of urine and stool).During a review of Resident 2's Change of Condition Evaluation (COC) dated 12/25/2025 and timed at 12:58 a.m., the COC indicated Resident 2 had a fall and was found sitting on the lobby floor with blood on her face.
There was no documentation indicating Resident 2's vital signs were documented during the change of condition.During a review of Resident 2's Change in Condition Progress Notes dated 12/26/2025 and timed at 1:59 a.m., the Change in Condition Progress Notes indicated Resident 2 was found on the floor by the nursing station with a quarter sized cut on the forehead actively that was actively bleeding.
The Change in Condition Progress Notes indicated the paramedics (a group of individuals trained to provide emergency medical care to people who are injured or ill outside the GACH) were called and Resident 2 was transferred to a general acute care hospital (GACH) via 911 for further treatment.
There was no documentation indicating Resident 2's vital signs were documented during Resident 2's change of condition.During a telephone interview on 2/24/2026 at 11:51 a.m., RN 1 stated Resident 2 had an unwitnessed fall on 12/25/2025 at the change of shift (between 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m.). RN 1 stated he was able to assess and monitor Resident 2 vital signs during her change of condition but did not document Resident 2's vital signs in her clinical record. RN 1 stated he should have documented Resident 2's vital signs in the clinical record to depict Resident 2's accurate well-being after the fall.
During an interview on 2/24/2026 at 3:03 p.m., the Director of Nursing (DON) stated RN 1 should have documented Resident 2's assessments and monitoring during the change of condition to include current vital signs to reflect the accurate well-being of Resident 2 after her fall and her condition and/or deterioration was determined.
The DON stated it was the responsibility of the nursing staff to ensure the residents' records are complete.During a review of the facility's policy and procedure (P&P) titled, Documentation in Medical Record, revised 12/19/2022, the P&P indicated the following:a.
The residents' medical records shall contain a representation of the residents' experiences and should reflect enough information to provide a picture of the residents' progress, andb.
The nursing staff shall document all accurate, relevant and complete assessments, observations, and services provided and all documentation must be completed at the time of service.