Cottage Grove Post Acute

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide appropriate pain management for 2 of 2 sampled residents (#s 33 and 39) reviewed for pain management. This failure resulted in Resident 39 not receiving her/his scheduled narcotic pain medications for three days which caused the resident to suffer from narcotic withdrawal, increased pain, and an avoidable hospitalization. This placed residents at risk for narcotic withdrawal and increased pain.

Inspectors wroteBased on interview and record review it was determined the facility failed to complete timely MDS assessments for 4 of 8 sampled residents (#s 20, 21, 32, and 33) reviewed for MDS and unnecessary medications. This placed residents at risk for unassessed needs.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide palatable food to 1 of 1 kitchen and 2 of 4 (#s 4 and 33) residents reviewed for food and kitchen tasks. This placed residents at risk for weight loss and reduced quality of life.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to follow infection control standards for 1 of 3 halls (West Hall) and 1 of 1 sampled resident (#28) during random observations. This placed residents at risk for exposure and contraction of infectious diseases.

Inspectors wroteBased on interview and record review it was determined the facility failed to notify the physician of the resident's discharge to the hospital for 1 of 1 sampled resident (#39)reviewed for hospitalizations. This placed residents at risk for delayed treatment.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to exercise reasonable care for the protection of the resident's property from loss or theft for 1 of 2 sampled residents (#38) reviewed for personal property. This placed residents at risk of loss or theft of property.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure appropriate information was communicated to the receiving health care institution or provider prior to a resident being transferred to the hospital for 1 of 1 sampled resident (#39) reviewed for hospitalization. This placed the resident at risk for unassessed needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to complete a Significant Change MDS assessment (SCSA) within the required 14 days after a determination of a significant change of condition of a resident for 1 of 1 sampled resident (#39) reviewed for hospitalizations. This placed residents at risk for unassessed care needs.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to complete a baseline care plan within 48 hours of a resident's admission for 1 of 1 sampled resident (#32) reviewed for pressure ulcers. This placed residents at risk for unmet wound care needs.

Inspectors wrote2. Resident 38 was admitted to the facility in 2/2025 with a diagnoses including hypertensive heart disease with heart failure (a condition where the heart cannot pump blood effectively). Physician orders with a start date of 3/15/25 instructed staff to obtain Resident 38's weight every day shift on Saturdays for weight monitoring. A review of Resident 38's weights report revealed from 3/29/25 through 6/2/25, Resident 38's weight was documented on the report as obtained out of 12 times physician ordered. The 5/2025 TAR instructed staff to obtain weekly weights every day shift every Saturday for weight monitoring with a start date of 3/15/25. The TAR was documented as NA three times, a weight of 172 one time, and a code six one time. There was no legend for what NA was defined as. Code six was indicated as glucose. [...]

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident pain medication was not misappropriated for 1 of 3 sampled residents (#3) reviewed for abuse. This placed residents at risk for increased pain.

Inspectors wroteBased on interview and record review it was determined the facility failed to store narcotic pain medications in a safe manner. This placed residents at risk for misappropriation of medications.

Inspectors wroteBased on interview and record review it was determine the facility failed to ensure the dietary manager had current certification for 1 of 1 kitchen reviewed. This placed residents at risk for unmet dietary needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 5 of 5 sampled CNA staff (#s 17, 18, 19, 20, and 21) reviewed for staffing. This placed residents at risk for a lack of competent staff.

Inspectors wroteBased on interview and record review it was determined the facility failed to complete a baseline care plan within 48 hours of a resident's admission for 1 of 2 sampled residents (#253) reviewed for respiratory care. This placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure dependent residents received assistance with nail care for 2 of 5 sampled residents (#s 15 and 18) reviewed for ADLs. This placed residents at risk for poor hygiene and unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow a physician's order for daily weights for 1 of 2 residents (#14) reviewed for respiratory care. This placed residents at risk for delay in treatment.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide respiratory care and services in accordance with physician orders for 1 of 2 sampled residents (#253) reviewed for respiratory care. This placed residents at risk for unmet respiratory needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to prevent the development of a pressure ulcer, failed to ensure accurate and completed wound assessments, failed to care plan the pressure ulcer and failed to demonstrate the resident's clinical condition made the development of a pressure ulcer unavoidable for 1 of 1 sampled resident (#35) reviewed for pressure ulcers. This resulted in Resident 35 developing an unstageable (full thickness skin preventing view of the depth of the wound) pressure ulcer.

Inspectors wroteBased on observation and interview it was determined the facility failed to provide a clean and well maintained environment for 5 of 30 resident room floors and 1 of 3 carpeted halls. This placed residents at risk for lack of a clean and homelike environment.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from abuse for 3 of 5 sampled resident (#s 9, 20 and 2) reviewed for abuse. This placed residents at risk for abuse.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure professional standards were followed for medication administration for 1 of 3 halls reviewed for late medications. This placed residents at risk for medication complications or worsening conditions.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure narcotic records were reconciled based on standards of practice for 3 of 3 halls reviewed for narcotic reconciliation. This placed residents at risk for misappropriation of medications.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure significant medication errors did not occur for 7 of 17 residents (#s 12, 15, 16, 19, 22, 29 and 30) reviewed for medication administration times. This placed residents at risk for seizures, blood sugar, stomach and blood pressure issues and medication complications.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide assistance with a bedpan for 1 of 1 sampled resident (#91) reviewed for ADLs. This placed residents at risk for skin breakdown.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders and care plan for 3 of 8 sampled residents (#s 2, 28 and 33) reviewed for medications and ADLs. This placed residents at risk for unmet needs.