Deficiencies (last 6 years)
Deficiencies (over 6 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
39% better than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
58 residents
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Dec 29, 2025
Visit Reason
The inspection was conducted as a complaint investigation focusing on the facility's implementation of COVID-19 precautions for positive residents.
Findings
The facility failed to ensure appropriate COVID-19 precautions were followed by staff when caring for COVID-19 positive residents, including failure to wear required PPE such as N-95 masks, gowns, gloves, and face shields. This deficiency potentially affected all 58 residents in the facility.
Complaint Details
This deficiency is based on incidental findings discovered during the course of this complaint investigation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to implement appropriate COVID-19 precautions including proper use of PPE by staff when entering rooms of COVID-19 positive residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 58
Residents reviewed: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #30 | Did not wear appropriate PPE when entering COVID-19 positive resident's room | |
| Certified Nursing Assistant (CNA) #10 | Did not wear appropriate PPE when entering COVID-19 positive residents' rooms | |
| Certified Nursing Assistant (CNA) #11 | Did not wear required PPE while in a COVID-19 positive room | |
| Licensed Practical Nurse (LPN) #20 | Did not wear appropriate PPE when entering a COVID-19 positive room |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Sep 10, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure laboratory tests were completed as ordered by the physician for residents.
Findings
The facility failed to obtain and monitor ordered laboratory tests for two residents, resulting in missing lab results for several tests including CBC, CMP, albumin, prealbumin, transferrin, hemoglobin A1c, TSH, lipid panel, ferritin, B12, and vitamin D. This non-compliance was verified through record review, staff interviews, and policy review.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number 2602837.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide timely, quality laboratory services/tests to meet the needs of residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 58
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Physician #800 | Ordered laboratory tests for residents #01 and #44 | |
| Director of Nursing | DON | Verified missing lab results and confirmed orders during interview |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 3
Dec 11, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse and neglect at the facility, including failure to suspend staff pending an abuse investigation and failure to maintain proper infection control measures during resident care.
Findings
The facility failed to suspend a staff member pending an abuse investigation affecting one resident, and failed to ensure proper infection control measures during incontinence and catheter care for two residents. These failures were found during the complaint investigation and included staff not changing gloves or performing hand hygiene appropriately and not wearing gowns during catheter care as required by facility policy.
Complaint Details
The complaint investigation was triggered by an allegation of neglect reported by Resident #41's daughter that RN #81 refused to give medications on 11/09/24. The facility investigation began on 11/11/24 and closed on 11/15/24. RN #81 was not suspended during the investigation and continued to work full shifts. Infection control deficiencies were incidental findings during the complaint investigation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to suspend staff pending an abuse investigation affecting Resident #41. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure proper infection control measures during incontinence care for Residents #37 and #41, including failure to change gloves and perform hand hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to wear gown during catheter care for Resident #41 as required by Enhanced Barrier Precautions. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 2
Facility census: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #81 | Named in abuse allegation and investigation; not suspended during investigation | |
| Assistant Director of Nursing (ADON) #89 | Interviewed Resident #41 during abuse investigation | |
| Certified Nursing Assistant (CNA) #100 | Observed failing to follow infection control procedures during incontinence and catheter care | |
| Administrator | Confirmed details of abuse investigation and staff suspension status |
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 21, 2023
Visit Reason
The inspection was conducted as an annual survey of the Cottingham Retirement Community to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 3
Aug 19, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely notify a physician of a significant change in condition for Resident #55, resulting in immediate jeopardy to resident health and safety. Additional investigations included monitoring resident weight loss and staffing issues.
Findings
The facility failed to notify the physician timely about Resident #55's abnormally low blood pressure, leading to the resident's death. The facility also failed to monitor and address significant weight loss in four residents and did not have a registered nurse staffed for at least eight hours daily on one occasion. Corrective actions and staff education were implemented to address these issues.
Complaint Details
The complaint investigation was triggered by the failure to timely notify the physician of Resident #55's significant change in condition, specifically abnormally low blood pressure readings over several hours without physician notification, resulting in the resident becoming unresponsive and later dying. The investigation also included review of weight loss monitoring and staffing adequacy.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 1
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to timely notify the physician of a significant change in condition for Resident #55, resulting in immediate jeopardy and resident death. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to monitor resident weight losses and address changes in nutritional status timely for four residents (#05, #09, #20, and #52). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have a registered nurse staffed at least eight hours a day, seven days a week. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 57
Weight loss percentage: 13.6
Weight loss percentage: 9.9
Weight loss percentage: 13.5
Weight loss percentage: 12.12
Blood pressure: 77
Blood pressure: 47
Blood pressure: 73
Blood pressure: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #170 | Licensed Practical Nurse | Failed to notify physician timely about Resident #55's low blood pressure; found resident unresponsive |
| Director of Nursing | Director of Nursing | Reviewed Resident #55's record, provided staff education, and monitored corrective actions |
| Regional Director of Clinical Services #500 | Regional Director of Clinical Services | Reviewed Resident #55's record and corrective action plan |
| Medical Doctor #300 | Primary Care Physician | Provided expectations for notification and treatment of low blood pressure |
| Registered Dietician #100 | Registered Dietician | Confirmed lack of timely reweighs and follow-up assessments for residents with weight loss |
| Director of Nursing | Director of Nursing | Confirmed no registered nurse staffed on 08/07/22 |
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 3
May 2, 2019
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements related to resident safety, medication administration, and infection control.
Findings
The facility was found deficient in ensuring fall interventions were in place for residents at risk, maintaining medication administration error rates below 5%, and implementing an effective infection prevention and control program, specifically failing to maintain separation of clean and soiled linen.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure fall interventions were in place for Resident #18, including lack of sensor alarm to bed to alert staff of attempted self transfers. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication administration error rate was 5 percent or below; observed error rate was 7.69% with two medication errors affecting two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain separation of clean and soiled linen in the laundry facility, potentially affecting all residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication opportunities observed: 26
Medication errors: 2
Medication error rate (%): 7.69
Residents affected by medication errors: 2
Residents reviewed for accidents: 4
Residents affected by fall intervention deficiency: 1
Residents affected by linen separation deficiency: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| State Tested Nursing Assistant (STNA) #11 | Reported Resident #18 did not have a sensor alarm in place to the bed to alert staff of attempted self transfers | |
| Licensed Practical Nurse (LPN) #9 | Confirmed medication error administering incorrect Vitamin D dosage to Resident #4 | |
| Licensed Practical Nurse (LPN) #725 | Confirmed medication error administering incorrect nasal spray dosage to Resident #23 | |
| Laundry Worker (LW) #700 | Confirmed storage of clean items on dirty side of laundry and long-term storage of cleaning discs on shelves |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 6
Apr 12, 2018
Visit Reason
The inspection was conducted due to complaints regarding failure to implement abuse policies, failure to timely report suspected abuse, failure to investigate multiple falls, failure to properly label and store food, failure to monitor antibiotic use, and failure to maintain essential equipment.
Findings
The facility failed to implement abuse policies for an injury of unknown origin, failed to timely report and investigate suspected abuse, failed to thoroughly investigate multiple falls for a resident, failed to label, date, and store food properly, failed to monitor antibiotic use appropriately, and failed to maintain wheelchair arm rests in good repair.
Complaint Details
The complaint investigation focused on allegations of failure to implement abuse policies, failure to report and investigate injuries of unknown origin, failure to investigate multiple falls, failure to properly label and store food, failure to monitor antibiotic use, and failure to maintain equipment. The facility census was 48. The investigation found substantiated deficiencies in all these areas.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to implement policies and procedures to prevent abuse, neglect, and theft related to an injury of unknown origin on a resident's inner thigh. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to thoroughly investigate multiple falls for one resident, including lack of documentation of root causes and interventions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to label, date, and store food in a manner to prevent potentially spoiled items from being served to residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to identify one resident receiving antibiotic eye drops continuously without appropriate monitoring or stop date. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain wheelchair arm rests in good repair, affecting two residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 48
Number of falls for Resident #31: 8
Dates of falls for Resident #31: 8
Dates of food items: Mar 20, 2018
Dates of food items: Feb 19, 2019
Dates of food items: Mar 21, 2019
Start date of antibiotic order: Nov 22, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Investigated Resident #31's bruise and falls; interviewed regarding fall investigations |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding bruise investigation, fall investigations, antibiotic stewardship, and wheelchair maintenance |
| Medical Director #101 | Medical Director | Interviewed regarding bruise of unknown origin on Resident #31 |
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding awareness and reporting of Resident #31's bruise |
| Dietary Manager | Dietary Manager | Interviewed and observed during kitchen tour regarding food labeling and storage |
| Maintenance Director | Maintenance Director | Interviewed regarding wheelchair armrest repairs |
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