The Cottages

Inspectors wroteBased on clinical record review, staff interviews, resident interview and policy review the facility failed to ensure resident safety when ambulated and when transferred to a chair without a gait belt for 1 of 3 residents reviewed (Resident #2). The fall resulted in a hip fracture that required surgery. The facility reported a census of 90 residents.

Inspectors wroteBased on clinical record review, policy review, staff interviews, resident and family interview the facility failed to provide dignity and respectful treatment for 1 of 3 residents reviewed. The facility reported a census of 90.

Inspectors wroteBased on record review, facility investigation file, staff interviews, and policy review, the facility staff failed to treat residents with dignity and respect and honor the resident's right when a resident refused to take a shower, and failed to protect residents from abuse by not conducting a thorough investigation of the incident for 1 of 2 residents reviewed for abuse (Residents #2) The facility reported a census of 86 residents.

Inspectors wroteBased on clinical record review, facility investigation file review, staff interviews, and policy review, the facility failed to report and allegation of abuse to the Iowa Department of Inspections, Appeals and Licensing within the required time for 2 of 2 residents reviewed for abuse (Residnt#1 and Resident#2). The facility reported a census of 86 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interviews, the facility failed to create and implement interventions to prevent a fall which resulted in an ER visit for 1 of 3 residents reviewed for falls(Resident #20). The facility reported a census of 95 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to ensure staff attempted non-pharmacological interventions prior to the administration of as needed(prn) anti-anxiety medications for 1 of 3 residents reviewed for anti-anxiety medications(Resident #3). Along with the anti-anxiety medication a opiod analgesic (strong pain med) was also given in most cases at the same time with no non-pharmalogical interventions for relief of pain attempted, or waiting for effectiveness of either medication. The facility reported a census of 95 residents.

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to ensure that a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for 2 of 20 residents reviewed for care planning (Resident #7 and #8). The facility reported a census of 95 residents.

Inspectors wroteBased on clinical record review, observation, staff interviews, and policy review, the facility failed to ensure safe and accurate delivery of oxygen therapy for one of three residents reviewed for respiratory care (Resident #86). The facility reported a census of 95 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to ensure the availability of routine medications for 1 of 4 newly admitted residents(Resident #99). The facility reported a census of 95 residents.

Inspectors wroteBased on clinical record review, observation, staff interview, and policy review, the facility failed to assure a medication error rate of less than 5%. During observation of medication administration, the facility had 3 errors out of 27 opportunities for error resulting in an error rate of 11.11% (Residents #25 and #66). The facility identified a census of 95 residents.1. The Quarterly Minimum Data Set (MDS) Assessment, dated 7/3/25, revealed Resident #25 had a diagnosis of diabetes. The MDS documented the resident took insulin during the 7-day lookback period. The Medication Administration Record (MAR), dated August 2025, for Resident #25 listed Lispro 100 milligrams (mg)/milliliter (ml), inject subcutaneously (SQ) per sliding scale before meals for blood glucose (sugar) 0-150=zero units (U); 151-200=6U; 201-250=8U; 251-300=10U; 301-350=12U; [...]

Inspectors wroteBased on clinical record review, observation, staff interview and review of facility policy, the facility failed to give an insulin prior to the meal as ordered for one of one residents observed who received insulin during medication pass (Resident #25). The facility reported a census of 95 residents. The Quarterly Minimum Data Set (MDS) Assessment, dated 7/3/25, revealed Resident #25 had a diagnosis of diabetes. The MDS documented the resident took insulin during the 7-day lookback period. The Medication Administration Record (MAR), dated August 2025, for Resident #25 listed Lispro 100 milligrams (mg)/milliliter (ml), inject subcutaneously (SQ) per sliding scale before meals for blood glucose (sugar) 0-150=zero units (U); 151-200=6U; 201-250=8U; 251-300=10U; 301-350=12U; 351-400=14U and scheduled at 7:00 AM, 11:00 AM and 4:00 PM. [...]

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents reviewed for pressure ulcers (Resident #92). The facility reported a census of 95 residents.

Inspectors wroteBased on clinical record review, facility policy review, Centers for Disease Control and Prevention (CDC) guidelines, and staff interview, the facility failed to offer the pneumococcal vaccine to 1 of 5 sampled residents reviewed for immunizations (Resident #25). The facility reported a census of 95 residents. Review of CDC guidelines, dated 10/2024, revealed the following recommendations:Administer Prevnar 20 (PVC20), Prevnar 21 (PVC21), or Vaxneuvance (PVC15) for all adults 50 years or older who have never received any pneumococcal conjugate vaccine, or whose previous vaccination history is unknown. Review of the clinical record for Resident #25 revealed the following:The Quarterly Minimum Data Set (MDS) assessment, dated 7/3/25, identified an admission date of 7/12/24, the resident was over age [AGE], and had diagnoses that included diabetes and dementia. [...]

Inspectors wroteBased on observation, clinical record review, policy review, and staff interviews, the facility failed to provide additional interventions, and supervision after Resident#1 displayed exit seeking behaviors. The facility also failed to secured the facility's exterior doors so that cognitively impaired residents could not leave the building without staff knowledge. This resulted in Resident #1 leaving the building without the staff's knowledge in 29 degree Fahrenheit weather. The staff only realized Resident #1 had left the building when a visitor found Resident #1 lying on the ground. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident and for 3 of 3 additional cognitively impaired, independently mobile residents with access to this door (Residents #5, #6, #7). The facility identified a census of 93 residents. [...]

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to document an accurate code status for one of four residents sampled for advanced directives (Resident #147). The facility reported a census of 92 residents.

Inspectors wroteBased on clinical record review, resident and staff interviews, and facility document review, the facility failed to evaluate the need for and offer scheduled nutrition interventions related to on-going weight loss and poor intake at meals. The facility also failed to update Resident 72's Care Plan to accurately reflect current staff interventions for weight loss, if any provided, and update the Care Plan for one of three residents reviewed for nutrition (Resident #72). The facility reported a census of 92 residents.

Inspectors wroteBased on record review, observations, staff interviews, and facility policy review, the facility failed to follow enhanced barrier precautions (EBP) and infection control practices to prevent the potential spread of infection or disease for 2 of 18 residents sampled (Resident #37). The facility staff also failed to appropriately cleanse and disinfect resident care devices after a tube feeding and medications administered through a gastrostomy tube (Resident #69). The facility staff also failed to wash hands or complete proper hand hygiene in-between dirty to clean tasks for 1 of 6 households observed. The facility reported a census of 92 residents.

Inspectors wroteBased on clinical record review, resident and staff interviews, the facility failed to ensure a resident had at least 2 baths/showers per week for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 95 residents.

Inspectors wroteBased on facility record review, family interview and staff interviews , the facility failed to answer the residents' call lights in less than 15 minutes for 4 of 4 residents reviewed (Resident #30, 42, 57, 75). The facility reported a census of 74 residents.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to fully review and revise the care plan for 1 of 2 residents (Resident #43) who were sampled for care plan review. The facility reported a census of 74.

Inspectors wroteBased on observation, menu review, staff interviews and policy review, the facility failed to serve the appropriate portions for 3 of 3 residents who received pureed diets (Resident #1, #17, #68) for one of one meals observed.

Inspectors wroteBased on observation and staff interview, the facility failed to provide food served by a method to maintain a safe and appetizing temperature for one of three meal observations. The facility reported a census of 74.

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by improperly storing food in two of five kitchen areas. The facility reported a census of 74 residents.