Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cottage Grove Place during CMS and state inspections, most recent first.
A resident with intact cognition, wheelchair dependence, and multiple cardiac and neurologic comorbidities was transported from a cardiology appointment in a facility van while seated in a secured wheelchair but without a lap/shoulder restraint applied. Facility policies and the driver’s job description required that all passengers wear seatbelts and that residents be secured with restraints, and the van involved was equipped with a red lap belt and shoulder restraint system for wheelchair passengers. During the return trip, the driver braked and swerved to avoid another vehicle, causing the unrestrained resident to be thrown forward out of the wheelchair, over a folded middle-row seat, and into a face-down, upside-down position between the second-row seat and the back of the driver’s seat, where first responders found the resident unresponsive, pulseless, and cyanotic. Staff interviews and record review showed that driver training and proficiency testing were conducted on a different van model, there was no documented training on the specific restraint system in the incident van, manufacturer instructions were not available, and drivers reported they did not use the lap/shoulder restraints in that vehicle, leading to the resident being transported without the required seatbelt protection.
A resident with dementia, severe cognitive impairment, prior fall‑related fracture, and identified fall and wandering risks was care‑planned for mechanical‑lift transfers, wheelchair use, and close supervision. During a noon meal in the dining room, a CNA and a medication aide left the room with another resident to lay that resident down, leaving multiple residents still eating without staff present after an LPN had instructed them regarding the other resident. While the dining room was unsupervised for several minutes, the cognitively impaired, fall‑risk resident fell from the wheelchair; another resident witnessed the fall but could not intervene. Staff returned to find the resident on the floor with a right forehead hematoma and right shoulder pain, and later ED imaging confirmed an acute fracture of the right scapula. Interviews and records showed that facility expectations called for continuous supervision in the dining room when residents were present, but no written policy for dining room supervision existed at the time.
The facility failed to ensure sufficient staffing to respond to door alarms, resulting in alarms sounding multiple times without staff intervention. A family member silenced the alarms using a code, which was the same as the entry code for the building. The facility had 58 residents, 34 with moderate to severely impaired cognition. Staff interviews revealed that the alarms could not be heard from key areas, contributing to the lack of response.
A facility failed to ensure that a resident's psychotropic medications for anxiety and depression had corresponding diagnoses in their electronic health record. The resident's MAR showed prescriptions for Trazodone, Duloxetine, and Lorazepam, but the necessary diagnoses were missing. Interviews revealed the resident's anxiety and depression, and the DON acknowledged the oversight. The facility's policy lacked procedures to align medication with diagnoses.
A resident experienced significant weight loss due to the facility's failure to provide appropriate vegetarian dietary options and effective interventions. Despite being involved in menu planning, the resident frequently did not order enough food and primarily consumed milk. The resident refused the prescribed nutritional supplement, citing a dislike for the taste and an allergy to strawberries. Interviews with the DON and dietician confirmed the facility's lack of a specific weight loss policy and failure to meet the resident's dietary needs.
The facility failed to provide timely toileting assistance and proper hygiene practices for two residents, leading to potential infection risks. A resident was left without toileting for over four hours, and staff did not change gloves during incontinence care. Another resident was changed without proper barriers and glove changes. Additionally, a resident with wandering behavior urinated in inappropriate locations without interventions, and another resident did not receive baths as frequently as desired.
The facility failed to respond to call lights promptly for five residents, leading to a deficiency in staffing adequacy. Residents reported and observations confirmed delays ranging from 18 minutes to over an hour. The DON and Administrator acknowledged the lack of call light audits and tracking systems, contributing to the issue.
A resident with severe cognitive impairment experienced medication refusals, a fall, and significant weight loss without family notification. The facility's policy required notifying the family of such changes, but documentation of these notifications was absent.
The facility failed to administer medications correctly for three residents, leading to inconsistent dosing times, missed insulin administration, and a delay in Prednisone delivery. A resident with intact cognition received medications at incorrect times due to unclear scheduling instructions. Another resident with diabetes did not receive insulin as ordered, and the physician was not notified of low blood sugar. A third resident did not receive a Prednisone taper due to pharmacy delays, resulting in hospitalization. The facility's policies for medication administration and physician order transcription were not followed.
The facility failed to obtain timely treatment orders and assessments for residents with skin conditions, including a resident with a new skin area, another with moisture-associated skin damage, and a third with a surgical wound infection. Delays in treatment and assessment led to hospital transfers and inadequate care, contrary to facility policies.
A resident developed a Stage 3 pressure injury on the left foot due to inadequate monitoring of a wander guard device. The resident, at risk for pressure injuries, had the device initially placed on the ankle, which caused skin breakdown. Despite care plan interventions, the facility failed to document regular checks on the device's placement, leading to the injury's progression. The facility's policy required regular skin assessments, but these were not effectively implemented, contributing to the injury's development.
A resident with severe cognitive impairment and a history of wandering was left unsupervised, leading to unsafe actions and inappropriate voiding. Despite a care plan requiring supervision, the resident was observed wandering unsupervised and engaging in hazardous behaviors. Staff interviews indicated insufficient staffing levels to adequately supervise residents with behavioral issues, contributing to the facility's failure to prevent accidents and hazards.
A resident with moderate cognitive impairment and a gastrostomy tube did not receive proper enteral feeding care. An LPN failed to prime the feeding tube, and the resident's head of bed was not elevated to the required 30 to 45 degrees during feeding, contrary to facility policy. The DON confirmed these expectations, highlighting a deficiency in care.
A resident with diabetes and other conditions did not receive their prescribed Rybelsus medication upon arrival at the facility. The pharmacy filled the prescription, but the facility delayed signing for it due to cost approval issues, resulting in the resident using their own supply initially.
A resident with severely impaired cognition did not receive the required Speech Therapy services as per their certification periods. The resident was scheduled for 12 therapy sessions from late November to late December but only received six. During a subsequent period, the resident was scheduled for eight sessions but was discharged to the hospital without receiving any. Staffing challenges were cited as a reason for the missed sessions.
Failure to Use Wheelchair Lap/Shoulder Restraint During Van Transport Resulting in Resident Ejection
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident being transported in a facility van was protected from accident hazards through proper use of a lap and shoulder seatbelt restraint. A cognitively intact resident who used a wheelchair for mobility and was dependent for transfers was transported from a cardiology appointment in a company-operated van. The resident had significant medical conditions including atrial fibrillation, heart failure, prior CVA with hemiplegia, DVT, and was receiving antiplatelet therapy, with anticoagulation recently on hold. Care plan interventions directed staff to use extra caution with transfers and positioning and to avoid activities that could result in injury or falls. Despite this, during the transport in the van involved in the incident, the driver did not secure a lap and shoulder restraint across the resident while she was seated in her wheelchair in the rear of the van. During the return trip from the appointment, the driver reported traveling below the posted speed limit when another vehicle pulled into the van’s path, prompting him to brake and swerve to avoid a collision. The resident’s wheelchair had been locked and secured to the floor, but no lap/shoulder restraint was applied. As a result of the abrupt maneuver, the resident was thrown forward out of the wheelchair, over a folded second-row seat, and came to rest face down and upside down between the folded second-row seat and the back of the driver’s seat, with her head near the floorboards. First responders found the resident unresponsive, pulseless, apneic, and cyanotic from the neck up, with blood from the nose and a few wounds from the fall. EMS documentation described the position as making adequate assessment impossible until she was removed from the van, and the presumed etiology of cardiac arrest was suspected positional asphyxia. Subsequent review of the van and staff interviews showed that the vehicle was equipped with a red lap belt and a shoulder restraint system designed for wheelchair passengers, but the lap belt was found rolled up on the floor and the shoulder belt was present in the rear of the van. A police officer and EMS documentation indicated it was believed the resident did not have a lap belt secured during the accident, and injuries were consistent with being ejected from the wheelchair. The driver stated he had been trained to secure wheelchairs and to use lap/shoulder restraints in a different van model, but reported he had not been taught how to use the lap/shoulder restraints in the van involved in the incident and that he never used them in that vehicle. Other drivers and the Environmental Services Director confirmed that driver training and proficiency testing were conducted using a different van, that there was no documentation of specific training on the incident van’s restraint system, and that manufacturer’s instructions for the lap/shoulder restraints were not available. Facility policies and the driver’s job description required that all passengers wear seatbelts and that residents be secured with restraints during transport, but the actual practice in the incident van did not include consistent use of the lap/shoulder restraints for wheelchair-seated residents, leading to the resident being transported without this protection at the time of the event. The facility’s internal incident report and root cause analysis acknowledged that they were unable to confirm that an over-the-lap or cross-body seat belt had been applied in addition to securing the wheelchair, and that this may have contributed to the resident moving forward in the van compartment during braking. The Fleet Management Program required pre-use safety checks and mandated that drivers ensure all passengers are secured by seat belts before the vehicle is in motion, and the driver’s job description emphasized resident safety and following procedures for securing residents with restraints. However, the Driver Proficiency Test did not specify which vehicle was used and did not include evaluation of securing wheelchair residents with lap/shoulder restraints for each vehicle type. The Facility Assessment Tool also did not identify transportation as a service or drivers as staff, despite the facility operating a bus and two vans for resident transport. These omissions and inconsistencies in training, documentation, and implementation of seatbelt use directly preceded the transport of the resident without a lap/shoulder restraint and the subsequent fatal incident when the van driver swerved and braked. The Immediate Jeopardy began on the day the resident was transported without the use of a lap and shoulder restraint and was identified by the State Agency during the survey. The facility’s own summary of the alleged incident, along with external reports from police, fire, and EMS, consistently documented that the resident was secured in the wheelchair but not with a lap/shoulder belt at the time of the event. The physical inspection of the van confirmed the presence of the restraint equipment that was not in use, and staff interviews revealed a pattern of incomplete, vehicle-specific training and lack of written or manufacturer guidance on the restraint systems. Collectively, these findings show that the facility failed to ensure the environment of transportation was free from accident hazards and failed to provide adequate supervision and implementation of required securement procedures to prevent the resident’s ejection from the wheelchair during an emergency driving maneuver.
Unsupervised Dining Room Leads to Unwitnessed Fall and Shoulder Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an accident‑hazard‑free environment in the dining room, resulting in an unwitnessed fall and fracture for one resident. The resident had severe cognitive impairment, a history of falls with fracture within the prior six months, and multiple diagnoses including fractures, hypertension, diabetes, and dementia. Care plans identified the resident as at risk for wandering and falls, required substantial/maximal assistance for transfers with a mechanical lift, use of a wheelchair for mobility, and continuous use of a left upper extremity immobilizer. The care plans also documented a prior facility fall on 11/3/2025 when the resident slid out of bed, and fall risk evaluations on 10/22/2025 and 11/28/2025 confirmed the resident was a fall risk. On the day of the incident, the resident was in the dining room in a wheelchair during the noon meal. Two staff members, a CNA and a medication aide, were present in the dining room assisting residents with eating and passing medications. Another resident in the dining room was reportedly refusing to eat and “not acting right,” prompting staff to call an LPN from upstairs to assess that resident. The LPN came to the dining room, observed the two staff assisting residents, and told them to lay the other resident down. Accounts differ on timing and interpretation: the CNA and medication aide reported they understood this as an immediate directive and left the dining room with the other resident, while the LPN stated she meant for the lay‑down to occur when staff did their regular lay‑downs and that the residents in the dining room should have been removed or one staff member should have remained. When the CNA and medication aide left the dining room, residents were still eating and no other staff remained in the room. The two staff took the other resident to her room, transferred her to bed using a stand‑up lift, and provided cares, which took approximately 8–15 minutes. During this period, the dining room was unsupervised. While they were away, a male resident witnessed the cognitively impaired, fall‑risk resident fall but was unable to intervene. Upon returning, staff found the resident on the floor on her right side with the wheelchair nearby; she had been seated at a table in her wheelchair when they left. The resident had a hematoma to the right forehead, right shoulder pain, and later imaging in the ED showed an acute fracture of the distal tip of the right acromion of the right scapula. The facility administrator and ADON later confirmed that residents in the dining room were expected to be under supervision while eating and that there was no specific written policy for dining room supervision at the time of the incident. The facility’s self‑report and subsequent interviews confirmed that the fall was unwitnessed and occurred in the dining room shortly after lunch, during a period when no staff were present. The resident, who was unable to provide a reliable history due to dementia, was found seated upright on the floor with legs extended and guarding her right shoulder. The ED documentation noted the unwitnessed fall, right forehead hematoma, right shoulder pain, and contusion to the right side of the face, with imaging confirming the right scapular fracture and no acute intracranial or spinal injury. Staff interviews consistently indicated that facility expectations had been communicated verbally or in meetings that at least one staff member should remain in the dining room when residents were present and eating, but on the day of the incident, both staff assigned to the dining room left simultaneously, leaving the resident and others unsupervised. The report also describes the sequence of clinical assessment and diagnostic imaging following the fall. After the incident, the LPN obtained orders for cervical spine and right shoulder X‑rays and contacted the portable X‑ray company, which initially indicated same‑day availability. When the company later could not come until several days later, the resident was sent to the ED for urgent evaluation due to increased pain. The ED confirmed the right scapular fracture and the resident returned with a right arm sling. Nursing staff on subsequent shifts were aware that the resident was awaiting imaging and reported that the resident was sleeping and did not recall complaints of pain during their checks, but the documentation and ED findings confirmed that the resident had sustained a significant injury as a result of the unwitnessed fall in the unsupervised dining room.
Failure to Respond to Door Alarms
Penalty
Summary
The facility failed to ensure sufficient staffing to respond to door alarms, which resulted in alarms sounding multiple times without staff intervention. On the day of the incident, two door alarms sounded four times within a 14-minute period, and no staff were present to respond. A family member was observed silencing the alarms using a code, which was the same as the entry code for the building. The facility had 58 residents, 34 of whom had moderate to severely impaired cognition as indicated by their Brief Interview for Mental Status (BIMS) scores. Five residents used wander guards for safety, and 14 residents lived in proximity to the alarmed doors, with 9 of them having a BIMS score of 12 or lower. Interviews with staff revealed that the door alarms could not be heard from key areas such as the dining room and the nurse's desk, which contributed to the lack of response. Staff members were unaware of any recent incidents of residents leaving the building unassisted, but acknowledged that if an alarm was heard, they were expected to check the grounds. The Director of Nursing and the Administrator confirmed the issues with the alarm system, including the inability to run reports on alarm frequency and the inappropriate deactivation of alarms by family members.
Lack of Diagnoses for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that psychotropic medications administered to a resident for anxiety and depression had corresponding diagnoses in the resident's electronic health record. This deficiency was identified for one of the three residents reviewed, specifically Resident #6. The resident's Medication Administration Record (MAR) indicated prescriptions for Trazodone, Duloxetine, and Lorazepam, intended for depression and anxiety. However, the electronic health record lacked documented diagnoses of depression and anxiety, despite the resident's care plan including focus areas for these conditions. During interviews, Resident #6 expressed feelings of anxiety and depression following a stroke, and staff confirmed the resident's confusion and anxiety. The Director of Nursing acknowledged the absence of the necessary diagnoses in the electronic health record and recognized the need for further investigation. Additionally, the facility's medication administration policy did not include procedures to ensure that medication diagnoses aligned with resident diagnoses, contributing to the oversight.
Failure to Prevent Weight Loss in Vegetarian Resident
Penalty
Summary
The facility failed to implement effective interventions to prevent weight loss for a resident who was identified as a vegetarian and had specific dietary preferences and allergies. The resident, who had no cognitive impairments, required set-up assistance with eating and had a history of anemia, hypertension, chronic pain, and malaise. Despite being involved in menu planning, the resident frequently did not order enough food and primarily consumed milk during meals. The care plan included monitoring weights, providing a regular diet, and offering vegetarian food choices, but these interventions were not effectively implemented. The resident experienced significant weight loss over several months, with a noted decrease of 10 pounds in one month and a total loss of 16.8 pounds since January. The facility's records indicated that the resident refused the prescribed nutritional supplement, Boost Plus, multiple times, citing a dislike for the taste and an allergy to strawberries, which was the flavor provided. The resident expressed a preference for tofu and other vegetarian protein sources, which were not accommodated by the facility's general diet offerings. Interviews with the facility's DON and dietician confirmed that the facility did not have a specific weight loss policy and only provided a general diet, failing to meet the resident's vegetarian dietary needs. The facility acknowledged the responsibility to furnish appropriate foods for the resident's diet and recognized the need to develop a diet plan that aligns with the resident's preferences and nutritional requirements.
Deficiencies in Resident Care and Hygiene Practices
Penalty
Summary
The facility failed to provide timely toileting assistance and adhere to proper hand hygiene and personal protective equipment guidelines during incontinence care for two residents. Resident #21, who was always incontinent of bowel and bladder and dependent on staff for toileting, was observed sitting in a wheelchair for over four hours without being offered toileting. During incontinence care, staff failed to change gloves between clean and dirty tasks and did not follow proper wiping techniques, increasing the risk of infection. The Director of Nursing (DON) acknowledged the staff's failure to change gloves and the absence of a peri care or toileting policy. Resident #27, also incontinent and dependent on staff for toileting, was observed being changed without proper use of barriers and glove changes. Staff placed dirty wipes and briefs directly on the bed without a barrier and touched clean items with dirty gloves. The DON confirmed that the staff should have changed gloves and used barriers during the process. The facility also failed to implement interventions to prevent inappropriate voiding for Resident #34, who exhibited wandering behavior and severe cognitive impairment. Despite frequent incidents of urination in inappropriate locations, the facility did not have a toileting program in place for the resident. Additionally, Resident #48 did not receive baths according to their desired frequency, with documentation showing fewer baths than the facility's policy required. The DON confirmed the expectation for residents to receive showers at least twice a week, which was not met for Resident #48.
Delayed Call Light Responses in LTC Facility
Penalty
Summary
The facility failed to respond to call lights in a timely manner for five residents, leading to a deficiency in providing adequate nursing staff to meet residents' needs. Resident #44, with intact cognition and requiring substantial assistance for daily activities, had a call light unanswered for 18 minutes. Resident #42, with moderate cognitive impairment and dependent on staff for activities, reported waiting 20-45 minutes for call light responses, and an observation confirmed a delay of 18 minutes. Resident #251, who required assistance from two people for mobility and toileting, reported long wait times due to staff shortages, and the Director of Nursing admitted to a lack of call light audits. Resident #48's representative reported that call lights were not answered promptly, with waits of 35 minutes to an hour, particularly when the resident was in a basement room. Resident #203, with intact cognition, experienced a 20-minute wait for assistance to use the bathroom. The facility's Director of Nursing and Administrator acknowledged that call lights should be answered within 15 minutes but admitted to not having conducted audits or having a system to track response times, contributing to the deficiency.
Failure to Notify Family of Resident's Condition Changes
Penalty
Summary
The facility failed to notify a resident's representative of several significant changes in the resident's condition. The resident, who had diagnoses including skin changes, diabetes, and non-Alzheimer's dementia, with a severely impaired cognition score, refused multiple medications on two separate occasions. These medications included donepezil, carbidopa-levodopa, metformin, and vinpocetine. Additionally, the resident refused a Med Pass supplement. There was no documentation indicating that the family was notified of these medication refusals. Furthermore, the resident experienced a fall, as noted in health status notes, but the facility could not locate a fall incident report. The family was not informed of the fall. The resident also experienced a significant weight loss from 172 lbs to 161 lbs, as noted in a physician fax, but again, there was no documentation of family notification. The facility's policy required staff to report changes in a resident's condition to both the physician and the family, which was not adhered to in these instances.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to administer medications in accordance with professional standards for three residents. Resident #203, who had intact cognition, received her medications at incorrect times over several days. The facility's medication administration schedule lacked clear instructions for administering medications ordered twice daily, leading to inconsistent dosing times. The Director of Nursing (DON) and an Advanced Registered Nurse Practitioner (ARNP) acknowledged the inappropriate practice of administering medications within broad time frames, which was not aligned with professional standards. Resident #33, with moderate cognitive impairment and insulin-dependent diabetes, did not receive her prescribed insulin dose on one occasion, and the nurse failed to notify the physician when the resident's blood sugar was low. The nurse misinterpreted the order, believing insulin should be held if blood sugar was below a certain level, which was incorrect. The DON confirmed that the nurse should have contacted the physician for further instructions, highlighting a lapse in following the facility's policy for physician order transcription and medication administration. Resident #204, who required continuous oxygen therapy and had multiple diagnoses, did not receive a prescribed Prednisone taper due to a delay in medication delivery from the pharmacy. The facility failed to notify the physician about the missing medication, and the resident experienced respiratory issues, leading to hospitalization. The facility had an emergency medication kit that included Prednisone, but it was not utilized. The DON and Facility Administrator acknowledged the failure to document physician notification and the transcription of orders into the electronic medical record, as required by facility policy.
Deficiencies in Timely Treatment and Assessment of Skin Conditions
Penalty
Summary
The facility failed to obtain a timely treatment order for a new skin area for a resident with diabetes and hip fracture, who required assistance for mobility and had intact cognition. The resident complained of soreness at the coccyx, and a new area was identified, but the treatment order was not documented until several days later, delaying the initiation of treatment. Another resident with severely impaired cognition and a history of skin changes and diabetes was not assessed or treated for moisture-associated skin damage (MASD) in a timely manner. The facility lacked documentation of skin assessments and treatments for MASD, and the resident was later transferred to the hospital with a Stage 2 pressure injury. Additionally, the facility did not assess or intervene when the resident showed signs of altered mental status, leading to a hospital transfer with symptoms of fever, confusion, and purulent drainage from a Foley catheter. A third resident, dependent on staff for mobility and with a history of joint replacement surgery, showed signs of infection at the surgical wound site. Despite the presence of redness, inflammation, and purulent drainage, the facility delayed notifying the provider and obtaining appropriate wound care orders. The facility's policy required immediate notification of the provider for signs of infection, but this was not adhered to, resulting in a delay in addressing the resident's wound infection.
Failure to Monitor Wander Guard Leads to Stage 3 Pressure Injury
Penalty
Summary
The facility failed to adequately monitor and assess the skin condition of a resident wearing a wander guard device, resulting in the development of a Stage 3 pressure injury on the resident's left inner foot. The resident, who had intact cognition and was at risk for pressure injuries due to limited mobility and other health conditions, was initially noted to have a new pressure area on the foot attributed to the wander guard. Despite the removal of the device from the ankle and its relocation to the wrist, the injury progressed from a scab to an unstageable pressure injury with slough and drainage. The resident's care plan included interventions for skin integrity and pressure injury prevention, such as wearing a heel boot and weekly skin evaluations. However, the care plan did not specifically address the pressure injury that developed. The facility's records lacked documentation of regular checks on the wander guard's placement and function, which was expected to be recorded in the Electronic Health Record. The resident's wound assessments over several months showed deterioration, with the injury eventually classified as a Stage 3 pressure injury. The facility's policy required regular skin assessments and immediate reporting of any changes, but these protocols were not effectively implemented. The Director of Nursing acknowledged that the wander guard had caused the initial skin breakdown due to the resident's side sleeping and contracted legs. Despite the facility's policy and the resident's care plan, the lack of consistent monitoring and documentation contributed to the progression of the pressure injury.
Inadequate Supervision of Resident with Wandering Behavior
Penalty
Summary
The facility failed to provide adequate supervision for a resident with severe cognitive impairment, resulting in unsafe actions and inappropriate voiding. The resident, who had a history of wandering and was at high risk for falls, was observed multiple times engaging in unsafe behaviors without staff intervention. These behaviors included urinating in inappropriate locations, wandering unsupervised, and interacting with potentially hazardous objects. The resident's care plan indicated a need for supervision and redirection due to their wandering behavior and potential for aggression. Despite this, the resident was frequently left unsupervised, as evidenced by multiple observations where the resident wandered into other residents' rooms, attempted to pick up non-existent objects, and urinated on the floor in the dining room. Staff interviews revealed that the lower level of the facility, where the resident resided, was often understaffed, with only one nurse or medication aide available to supervise multiple residents with behavioral issues. Staff members reported that the current staffing levels were insufficient to provide the necessary supervision for residents with wandering behaviors. The Director of Nursing expected staff to remain in common areas to monitor residents like the one in question, but observations showed that this expectation was not consistently met. The lack of adequate supervision and staffing contributed to the resident's unsafe actions and the facility's failure to prevent accidents and hazards.
Improper Administration of Enteral Tube Feeding
Penalty
Summary
The facility failed to properly administer enteral tube feeding to a resident with a gastrostomy tube, leading to a deficiency in care. The resident, who had moderate cognitive impairment and diagnoses including cancer and malnutrition, required tube feeding for a significant portion of their nutritional intake. During an observation, a Licensed Practical Nurse (LPN) prepared the tube feeding without priming the tubing, which is necessary to prevent air from entering the abdomen. Additionally, the resident's head of bed was not elevated to the required 30 to 45 degrees during the feeding process, as it remained at approximately 15 degrees. The facility's Director of Nursing (DON) confirmed the expectation that tubing should be primed before feeding and that the head of bed should be elevated appropriately during and after feeding. The facility's policy also instructed staff to maintain the head of bed elevation at least 30 degrees during feeding and for a period afterward. Despite these guidelines, the staff did not adhere to the proper procedures, resulting in a failure to provide appropriate care for the resident with a feeding tube.
Failure to Provide Routine Medications
Penalty
Summary
The facility failed to ensure the provision of routine medications for a resident diagnosed with diabetes, hip fracture, and pain, who had an intact cognitive status. The resident's Minimum Data Set (MDS) assessment indicated a need for Rybelsus, a medication used to improve blood sugar levels, with an order dated 12/7/23. However, the resident reported having to use her own supply of Rybelsus upon arrival at the facility because the medication was not available. The pharmacy had filled the prescription on 12/6/23, but the facility did not sign for it until 12/8/23. The delay was due to the pharmacy needing approval from the facility because of the medication's cost. The pharmacy contacted the facility on 12/6/23 and 12/7/23, receiving approval on 12/7/23. The Director of Nursing confirmed that for skilled residents, the facility was responsible for medication costs, and the admission packet indicated a contract with a pharmacy for pharmaceutical services.
Failure to Provide Required Speech Therapy Services
Penalty
Summary
The facility failed to provide the required Speech Therapy services for a resident with severely impaired cognition, as indicated by a BIMS score of 4 out of 15. The resident had a certification period for Speech Therapy from 11/24/23 to 12/21/23, during which they were supposed to receive therapy 12 times. However, documentation shows that the resident only received therapy on six occasions within this period. Additionally, during a subsequent certification period from 2/13/24 to 3/13/24, the resident was scheduled for eight therapy sessions but was discharged to the hospital on 2/25/24, with no documentation of any therapy sessions conducted between 2/13/24 and 2/25/24. The Director of Therapy acknowledged staffing challenges with speech therapists and was unable to explain why the resident did not receive the scheduled therapy sessions. The Director of Nursing confirmed that therapy should adhere to the number of visits ordered. The facility's policy, although undated and untitled, stated that therapists should provide rehabilitation services according to physician orders, which was not followed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cedar Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmony Cedar Rapids | 0.3 mi | ★★★★★ | 12 | 0 |
| Living Center West | 1.4 mi | ★★★★★ | 2 | 0 |
| St Luke's Helen G Nassif Transitional Care Center | 2.3 mi | ★★★★★ | 4 | 0 |
| Linn Manor Care Center | 2.4 mi | ★★★★★ | 10 | 0 |
| Meth-wick Health Center | 2.9 mi | ★★★★★ | 0 | 0 |
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