Cottingham Retirement Community

Based on review of the medical record, observations, staff interviews and policy review, the facility failed to ensure Coronavirus-19 (COVID-19) precautions were implemented appropriately for all positive residents.

This had the potential to affect all 58 residents residing in the facility.

The facility census was 58.

Findings include:

Review of the medical record for 24 residents (#1, #4, #6, #8, #10, #12, #13, #15, #19, #21, #23, #26, #37, #41, #44, #45, #48, #49, #50, #53, #56, #58, #63, and #64) revealed the residents had tested positive for COVID-19 when the outbreak started in the facility on 12/08/25.

Observation on 12/22/25 at 8:06 A.M. revealed Registered Nurse (RN) #30 went into Resident #26's room, who was COVID-19 positive, without wearing a N-95, gown, gloves, or face shield as required, to administer medications wearing a surgical mask only.

Interview on 12/22/25 at 8:09 A.M. with RN #30 verified she did not wear the appropriate personal protective equipment (PPE) as required when entering Resident #26's room. RN #30 confirmed Resident #26 was positive for COVID-19.

Observation on 12/22/25 at 8:28 A.M. revealed Certified Nursing Assistant (CNA) #10 was passing breakfast trays to residents. CNA #10 went into Resident #13's room, who was COVID-19 positive, to pass breakfast tray without wearing required PPE (gown, gloves, N-95, and face shield). CNA #10 was only wearing a surgical mask.

Observation on 12/22/25 at 8:32 A.M. revealed CNA #10 entered Resident #6's room, who was COVID-19 positive, to pass breakfast tray without wearing required PPE (gown, gloves, N-95, and face shield). CNA #10 was only wearing a surgical mask.

Interview on 12/22/25 at 8:34 A.M. with CNA #10 verified he did not wear the appropriate PPE when entering Resident #6's and forgot about it. CNA #10 confirmed Resident #6 was COVID-19 positive.

Observation on 12/22/25 at 8:43 A.M. revealed CNA #11 was in Resident #21's room, who was COVID-19 positive, wearing only a surgical mask.

Interview on 12/22/25 at 8:45 A.M. verified CNA #11 did not wear the required PPE while in a COVID-19 positive room.

Observation on 12/22/25 at 8:49 A.M. revealed Licensed Practical Nurse (LPN) #20 went into Resident #5's room to administer medications. Resident #5's roommate, Resident #6, who was positive for COVID-19. LPN #20 did not don a gown, gloves, N-95, or face shield when entering the room. LPN #20 wore a surgical mask.

Interview on 12/22/25 at 8:52 A.M. with LPN #20 verified she did not wear appropriate PPE when entering a COVID-19 positive room.

Review of the contact and droplet precautions signage revealed proper PPE was gown, gloves, N-95, and a face shield.

Review of the facility policy titled, CDC Recommendations regarding Outbreak, dated September 2025 revealed healthcare personnel (HCP) should follow all recommended infection prevention and control practices including wearing well-fitting source control, monitoring themselves for fever or symptoms consistent with COVID-19, and not reporting to work when ill or if testing was positive. HCP should wear appropriate PPE in the room (gown, gloves, eye protection, and respirator.

This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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