Cottage Grove Place

Inspectors wroteBased on clinical record review, staff interview, observation, fire department and police reports, ambulance reports, employee file review, and facility record review, the facility failed to utilize a lap and shoulder seatbelt restraint prior to transporting a resident in a facility van for 1 of 3 residents reviewed (Resident #1). On [DATE], during transport from a doctor's appointment, the facility van driver failed to secure a lap and shoulder seatbelt restraint for Resident #1, who was seated in a secured wheelchair in the back of a transport van. As a result, Resident #1 flew forward out of the wheelchair over a folded middle row seat when the driver swerved and braked to avoid another vehicle. Resident #1 landed face down on the folded second row seat, with her head near the floor between the second-row seating and back side of the driver's seat. [...]

Inspectors wroteBased on observation, clinical record review, and staff interviews the facility failed to provide appropriate supervision to prevent a fall that resulted in fracture of the resident's right scapula (shoulder blade) and pain for one of three residents reviewed (Resident #1). The facility reported a census of 55 residents.

Inspectors wroteBased on observations, staff interviews, and policy review the facility failed to provide sufficient dietary staff with the appropriate skills and competencies to safely and effectively provide food service to the facility residents. The facility reported a census of 59 residents. Findings Include: During observation of the facility puree process with Staff A, [NAME] on 04/29/25 at 10:30 am revealed the staff member lacked training and knowledge of the puree process. Staff A lacked instruction on how to complete the puree process and ensure puree diet residents get the same portions as regular diets. Staff A was uncertain how to measure out the puree content, did not know portion sizes and advised they serve pudding or ice cream instead of the dessert of the day. Staff served dessert and advised it was a bit runny and made no attempts to thicken before serving. [...]

Inspectors wroteBased on observation, staff interviews, facility documentation, and policy review, facility staff failed to ensure the internal temperature of food provided to the residents was cooked to the proper internal temperature and failed to document internal temperatures in the log book. The facility reported a census of 59 residents. Findings Include: After observation of the facility meal process with Staff A, [NAME] on 04/29/25 at approximately 11:50 am Staff A failed to log food temperatures into the log book. Staff A advised all food temperatures where taken prior to meal service and all temperatures met required internal temperatures and it was an oversight not to log the temperatures. On 04/29/25 at 12:05 pm the facility Registered Dietician, (RD) was queried regarding food temperatures and logging. [...]

Inspectors wroteBased on observation, policy review, resident and staff interview the facility failed to make reasonable accommodations for a resident to reach her clothes hanging in the closet for 1 of 1 residents reviewed (Resident #16). The facility reported a census of 59 residents.

Inspectors wroteBased on observation, a posted notice, record review, staff interview, and family interview the facility failed to ensure sufficient staffing to respond to door alarms that sounded in the facility. Two door alarms sounded 4 times in 14 minutes without a staff response. 34 of 58 residents in the facility scored 12/15 or lower on the Brief Interview for Mental Status (BIMS) assessment, which indicated they had moderate to severely impaired cognition. The facility reported a census of 58 residents.

Inspectors wroteBased on observation, record review, staff interview, resident interview, and policy review the facility failed to ensure psychotropic medications administered to a resident for anxiety and depression had matching diagnoses in the resident's electronic health record for 1 of 3 residents reviewed (Resident #6). The facility reported a census of 58 residents.

Inspectors wroteBased on observation, clinical record review, resident and staff interviews, the facility failed to implement interventions to prevent weight loss for 1 of 3 resident reviewed for weight loss (Resident #2). The facility identified a census of 50 residents.

Inspectors wroteBased on observations, interviews, and chart review the facility failed to offer toileting on a timely basis and failed perform proper hand hygiene and proper personal protective equipment guidelines to prevent the spread of potential infection and germs during incontinence cares for 2 of 3 residents reviewed (Residents #21, #27). In an observation it was discovered that Resident #21 was left in her chair for over 4 hours before offered toileting. Also, the facility failed to provide baths to residents per the resident's desired frequency for 1 of 4 residents reviewed (Resident #48). Facility further failed to put interventions in place to prevent voiding in inappropriate locations for 1 of 2 residents reviewed for wandering behavior (Resident #34). The facility reported a census of 53 residents.

Inspectors wroteBased on observation, resident, family, and staff interviews the facility failed to respond to call lights in a timely manner for 5 of 5 residents reviewed (Residents #42, #44, #251, #39, #203, #48 ). Facility reported a census of 53 residents.

Inspectors wroteBased on clinical record review, policy review, and staff and resident interviews, the facility failed to notify a resident's representative of a fall, medication refusals, and a significant weight loss for for 1 of 4 residents reviewed for a change in condition (Resident #48). The facility reported a census of 53 residents.

Inspectors wroteBased on clinical record review, policy review, and staff and resident interviews, the facility failed to administer medications in accordance with professional standards for 3 of 6 residents reviewed for medications (Residents #33, #203, and #204). The facility reported a census of 53 residents.

Inspectors wroteBased on clinical record review, policy review, and staff and resident interviews, the facility failed to obtain a treatment order for a new skin area in a timely manner for 1 of 3 residents observed with a non-pressure skin issue(Resident #203), failed to assess and carry out a treatment for a resident with moisture associated skin damage (MASD) for 1 of 3 residents observed with a non-pressure skin concern (Resident #48), failed to assess and intervene after a resident showed signs of altered mental status for 1 of 4 residents reviewed for a change in condition (Resident #48), and failed to assess and intervene when a surgical wound showed signs of infection for 1 of 3 residents revealed with a non-pressure skin concern (Resident #39). The facility reported a census of 53 residents.

Inspectors wroteBased on observation, interviews, clinical record review, and facility policy review, the facility failed to monitor and assess skin underneath a wander guard device which resulted in the development of a Stage 3, facility acquired, pressure injury of left inner foot for 1 of 4 residents reviewed for pressure injury (Resident #31). The facility reported a census of 53 residents.

Inspectors wroteBased on observations, interviews, and clinical record review, the facility failed to ensure adequate supervision of a resident known to wander, which resulted in unsafe actions and voiding in inappropriate locations for 1 of 2 residents reviewed for accidents and hazards (Resident #34). The facility reported a census of 53 residents.

Inspectors wroteBased on observation, interviews, clinical record review, and facility policy review, the facility failed to prime tubing prior to administration of enteral tube feeding and further failed to ensure the head of bed had been elevated to an appropriate level throughout administration of enteral feeding for 1 of 1 residents reviewed for feeding tube treatment and services (Resident #248). The facility reported a census of 53 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to ensure the provision of routine medications for 1 of 6 residents reviewed for medications (Resident #203). The facility reported a census of 53 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interviews, the facility failed to ensure the provision of Speech Therapy services for 1 of 1 residents reviewed for therapy services (Resident #48). The facility reported a census of 53 residents.

Inspectors wroteBased on clinical record review, staff and family interviews, the facility failed to appropriately assess and document skin alteration for one of three residents reviewed with pressure ulcers (Resident #4). The facility reported a census of 48 residents. Findings Include: 1. The admission Minimum Data Set (MDS) dated [DATE] for Resident #4, revealed the resident had severe cognitive impairment, required extensive assistance to transfer from one surface to another, failed to ambulate and had bowel and bladder incontinence. The MDS indicated the resident with a current Stage II pressure ulcer upon admission. The MDS dated [DATE] revealed Resident #4 with one unhealed Stage II pressure ulcer and diagnoses including diabetes, renal insufficiency, arthritis, anemia and muscle weakness. The Discharge MDS dated [DATE] indicated the resident without unhealed pressure ulcers. [...]

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to follow Physician's Orders that resulted in a medication error for one of nine residents reviewed (Resident #3). The facility reported a census of 48. Findings Include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #3 required assistance with transfers, eating and dressing. The resident had severe cognitive impairment and diagnoses including Parkinson's Disease, dementia and chronic pain. The resident's Care Plan revealed the resident with a history of falls and anxiety. The Care Plan directed staff to administer medications including Ativan, Benadryl and Haldol (ABH) cream as directed. The Care Plan instructed staff to educate resident/family of risks, benefits, side effects and toxic symptoms. [...]

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to address a medical diagnosis on the Care Plan for 1 of 12 residents reviewed for Care Plans (Resident #18). The facility reported a census of 45. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS documented the diagnosis of Type II DM (diabetes mellitus) with hyperglycemia and the resident received insulin 7 out of 7 days. The Care Plan dated 2/14/23 failed to reveal documentation of a focus problem and interventions for Type II DM. The Physician Orders are the following: a. Basaglar KwikPen U-100 Insulin 100 unit/ml (milliliter) (3 ml) subcutaneous every day- ordered on 2/28/23 b. Blood glucose checks two times weekly ordered on 2/6/23. [...]

Inspectors wroteBased on clinical record review, staff and resident interviews, the facility failed to consistently provide Care Conferences on a quarterly basis for 2 of 3 residents reviewed for Care Conferences (Resident #10, Resident #37). The facility reported a census of 45. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 scored 13 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The facility documentation lacked evidence a Care Conference occurred with the resident and the resident's family members with the Care Plan revision on 8/8/22. The facility documentation lacked evidence a Care Conference occurred with the resident and the resident's family members with the Care Plan revision on 3/27/23. [...]

Inspectors wroteBased on clinical record review, review of Fall Incident and Investigation Reports, observations and staff interviews, the facility failed to ensure fall interventions were consistently implemented for one of one resident reviewed for falls (Resident #40). The facility reported a census of 45 residents. Findings Include: The admission Minimum Data Set (MDS) Assessment for Resident #40 dated 2/13/23 revealed the resident scored 9 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident had moderately impaired cognition. Per this assessment the resident had fallen in the last month prior to admit, entry, or reentry. The resident also had a fracture related to a fall in the six months prior to admit. entry, or reentry. [...]