Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 The Cottages during CMS and state inspections, most recent first.
Failure to Respect Resident Refusal of Shower and Incomplete Abuse Investigation: Staff failed to honor a resident’s refusal of a shower and an RN forcefully removed the resident’s hand from a shower chair and took off her shirt while the resident repeatedly said no and stop. The resident had anxiety, depression, osteoarthritis, muscle weakness, and moderately impaired cognition. The facility’s investigation also lacked documentation of follow-up with other residents for potential abuse, police notification, and follow-up with other staff members working.
Failure to timely report abuse allegations: Two residents were involved in separate incidents that staff and management learned about before the state was notified. In one case, a CNA allegedly yelled at a resident, took a bed remote, and threw it toward the resident’s wound vac; in the other, an RN allegedly forcefully removed a resident’s shirt during shower care after the resident refused. Staff interviews and investigative files showed the allegations were known internally, but the DIAL report was delayed beyond the required timeframe.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors.
A resident admitted with multiple diagnoses did not receive several scheduled doses of prescribed medications, including Alrex eye drops, Pregabalin, and Duloxetine, due to the medications not being available at the facility. Documentation showed that staff did not follow up with the pharmacy or provider when the medications failed to arrive, and the resident eventually left the facility against medical advice. Staff interviews indicated uncertainty about the appropriate steps to take when medications were missing.
A resident with depression, mild cognitive impairment, behavioral symptoms, and musculoskeletal pain received repeated PRN lorazepam for agitation and PRN oxycodone for pain, often at the same time. The MAR and progress notes lacked documentation of non-pharmacological interventions before these doses or waiting for effectiveness between PRN medications, and the RN and DON stated that non-pharmacological interventions should be charted before PRN anti-anxiety medication use.
The facility failed to develop and implement comprehensive, person-centered care plans for two residents. One resident with dementia and anxiety had an antipsychotic-containing compounded ointment ordered for agitation, but the care plan did not include the medication. Another hospice resident had an O2 order and documented O2 use, but the care plan lacked O2 information. A third resident with severe transfer needs had a care plan that listed a walker assist instead of the EZ stand confirmed in the chart and by staff.
A resident with CHF, respiratory failure, pulmonary HTN, and hypoxia had an oxygen order that was inconsistently followed and documented. Surveyors observed the NC in place while the concentrator was off, the oxygen set below the ordered flow, and staff giving conflicting reports about whether the order was continuous or PRN. The EMAR/ETAR documented 4 L continuous, while staff stated the resident was actually on 2 L or PRN, and the facility policy lacked clear direction on reading and documenting oxygen flow.
Medication administration errors exceeded the allowed rate, with observed errors involving an RN and an LPN. One resident with diabetes received Lispro insulin later than ordered after the RN delayed it until after supper without physician notification, and another resident with dysphagia and hypothyroidism received Omeprazole and Levothyroxine after breakfast had already started, despite orders requiring administration before meals and on an empty stomach. The records lacked documentation of physician orders or notification for the timing changes.
A resident with diabetes was ordered lispro insulin before meals, but an RN checked the blood glucose, decided to hold the insulin until after supper because of concerns about intake earlier in the day, and then gave 10 units after the meal was finished. The record showed no physician order or documentation of notification for the delay, and the DON stated the nurse should not change the insulin timing using nursing judgment.
A facility failed to maintain its infection prevention and control program for a resident with an unhealed pressure injury on the foot and dementia-related self-care deficits. During toileting and transfer care, a CNA changed gloves without hand hygiene and handled the resident’s water pitcher while still gloved. During wound care, an LPN removed the dressing and cleansed the wound without changing gloves, changed gloves without hand hygiene, put away supplies with gloved hands, and handled trash without hand hygiene. The DON stated hand hygiene should occur between glove changes and after removing a dirty dressing, and the infection control manual did not address hand hygiene between glove changes.
Failure to offer the pneumococcal vaccine to a resident with diabetes and dementia. The resident had severe cognitive impairment and POA consent on file for the vaccine, but the clinical record lacked documentation of any PPSV23 or pneumococcal conjugate vaccine. The DON said the facility used a contracted pharmacy to track immunizations, but no evidence was found that the vaccine had been given.
A resident with severely impaired cognition left a facility unsupervised due to inadequate supervision and security measures. The resident, who had a history of confusion and exit-seeking behavior, was found outside in cold weather. The facility's elopement precautions were not followed, as door alarms were not activated, and the resident was not identified as at risk for elopement.
A facility failed to accurately document a resident's code status, leading to discrepancies between the EHR and the IPOST form. The resident was initially listed as Full Code in the EHR, while the IPOST indicated a DNR status. Staff interviews revealed a breakdown in the process of updating the EHR, with the SW responsible for obtaining signatures and updating records. The inconsistency was not corrected until several days later, despite staff reliance on the EHR for code status verification.
A facility failed to implement necessary nutritional interventions for a resident experiencing significant weight loss and poor meal intake. Despite the resident's cognitive impairments and medical conditions, the care plan was not updated to address low food intake. The RD did not document any interventions or rationale for the lack of action, even with significant weight loss identified. Staff interviews revealed a lack of awareness and documentation regarding the resident's dietary needs, and the facility's policy on nutritional interventions was not followed.
The facility failed to follow enhanced barrier precautions and infection control practices, risking infection spread for two residents. An LPN did not wear a gown while administering IV medication to a resident with a PICC line, and an RN did not properly clean a g-tube extension, risking cross-contamination. Additionally, a cook did not perform hand hygiene during meal preparation, as noted by the Director of Dining.
A resident with intact cognition and physical limitations due to a stroke, osteoporosis, and anxiety received only 3 baths/showers over a one-month period, despite the care plan directing staff to assist with bathing twice a week. The Clinical Quality Specialist confirmed the deficiency and noted the facility follows standards of care without a specific policy for baths/showers.
Failure to Respect Resident Refusal of Shower and Incomplete Abuse Investigation
Penalty
Summary
Facility staff failed to treat a resident with dignity and respect and failed to honor the resident’s right to refuse care when the resident refused a shower. The resident involved had diagnoses including anxiety disorder, depression, osteoarthritis, and muscle weakness, and the MDS indicated moderately impaired cognition with a BIMS score of 11 out of 15. The care plan directed staff to cue, reorient, supervise as needed, present one thought or command at a time, and leave the resident alone in a safe position and retry the task in a few minutes if the resident was resistive to care. On the morning of the incident, two CNAs attempted to get the resident up and into the shower. The resident stated she did not want a shower and said it was too cold. The resident was placed in a shower chair and remained adamant that she did not want to shower. When the CNA reported the refusal to the RN, the RN became upset and said she did not have time for this. The RN then entered the bathroom, told the resident she had to take a shower, pried the resident’s hand off the chair, and forcefully removed the resident’s shirt while the resident repeatedly said no and stop. Staff described the resident as clenching the chair, appearing scared, and being upset by the interaction. The facility’s investigation file contained conflicting staff statements about the event, but multiple accounts described the RN as forceful and frustrated. One CNA reported the RN said the resident had to shower and that staff could not always give a choice. Another staff member reported the RN said it was neglect if the resident did not get a shower. The resident later said the shower was terrible and too cold, and she described staff as mouthy and bossy. The investigation documented that the RN was removed from the unit and that the resident had no injuries on assessment, but the investigation lacked documentation of follow-up with other residents for potential abuse, police notification, and follow-up with other staff members working at the time.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the Iowa Department of Inspections, Appeals and Licensing within the required timeframe for two residents. The deficiency involved a reported allegation that a CNA yelled at a resident, took the bed remote away, and threw the remote toward the resident, and a separate allegation that an RN forcefully removed a resident’s clothing during shower care after the resident refused the shower. In both situations, the facility’s own investigation files and staff interviews showed that the incidents were known to staff and management before the state report was made, but the reports were not submitted within the required time. For the first resident, the record showed diagnoses including Alzheimer’s disease, dementia, a left femur fracture, and anxiety disorder. The resident had a BIMS score of 15 and required staff assistance for transfers, dressing, and toileting. The resident reported that an overnight CNA yelled at her, took her bed remote away after she raised the foot of the bed too high, and later threw the remote so that it struck her wound vac machine. Staff interviews confirmed that the concern was reported to nursing leadership the same evening, that the DOHS learned of it the next morning through a grievance form, and that the CNA was suspended pending investigation. The facility’s investigative file did not document when the allegation was reported to DIAL, and the report to the state was made after the incident had already occurred and after the facility had gathered additional information. For the second resident, the record showed diagnoses including anxiety disorder, depression, osteoarthritis, and muscle weakness. The resident had a BIMS score of 11 and required substantial to maximum assistance for upper body dressing and partial to moderate assistance for bathing. The resident refused a shower, and staff reported that an RN became upset, followed the CNA into the bathroom, pried the resident’s hand off the chair, and forcefully removed the resident’s shirt while the resident yelled no and stop. Staff reported the incident to nursing staff the same morning, the RN was removed from the unit, and the facility began an internal investigation. The investigative file did not list when the allegation was reported to DIAL, and staff interviews showed the facility waited until the following Monday to report the allegation after collecting statements and discussing whether enough information had been gathered.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment posed risks for accidents, and there was insufficient oversight to mitigate these hazards. Specific details regarding the nature of the hazards, the supervision provided, or the individuals affected were not included in the report.
Failure to Ensure Timely Availability of Routine Medications for New Admission
Penalty
Summary
The facility failed to ensure the timely availability of routine medications for a newly admitted resident with diagnoses including rheumatoid arthritis, weakness, and depression. Upon admission from a hospital, the resident had physician orders for Alrex eye drops, Pregabalin, and Duloxetine. Multiple doses of these medications were not administered as indicated by missing checkmarks and staff initials on the Medication Administration Record (MAR), with corresponding progress notes documenting that the medications were not available at the facility. The facility's policy outlined the process for obtaining medications from the pharmacy but did not address steps to take if medications did not arrive as expected. Progress notes and staff interviews confirmed that the medications were not available for several scheduled doses, and there was no documentation that staff contacted the pharmacy to follow up on the missing medications. The resident ultimately left the facility against medical advice. Staff interviews revealed a lack of clarity and action regarding obtaining the missing medications, with one RN stating she had received education to call the provider but had previously waited for the pharmacy. The DON stated that staff could request a stat delivery or contact the provider for orders, but this was not documented as having occurred during the incident.
Failure to Document Non-Pharmacological Interventions Before PRN Psychotropic and Pain Medication
Penalty
Summary
The facility failed to ensure staff attempted non-pharmacological interventions before administering PRN anti-anxiety medication for one resident reviewed for anti-anxiety medication use. The resident had diagnoses including depression, mild cognitive impairment, and muscle weakness, and the MDS also documented physical and verbal behavioral symptoms directed toward others during the 7-day review period, along with inattention and disorganized thinking. The care plan addressed musculoskeletal pain related to a left pubic fracture, lumbar disc degeneration, osteoarthritis, and knee pain, with interventions including analgesics as ordered and heat/cold applications as ordered and tolerated. The resident had PRN orders for lorazepam for agitation and oxycodone for pain, and the MAR documented multiple administrations of both medications, often at the same times. The record lacked documentation that staff attempted non-pharmacological interventions before these PRN doses or that staff waited for effectiveness before giving an additional PRN medication. The resident’s progress notes also lacked documentation of non-pharmacological interventions before the administrations. Staff interviews confirmed that non-pharmacological interventions should be documented prior to PRN anti-anxiety medication administration.
Incomplete Care Plans for Medication, Oxygen, and Transfer Needs
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan with measurable objectives and timetables was developed and implemented to meet residents' physical, psychosocial, and functional needs for 2 of 20 residents reviewed. For one resident with diagnoses of non-Alzheimer's dementia and anxiety, the Quarterly MDS showed delusions and rejection of care during the look-back period, and the physician's orders included a compounded ointment containing lorazepam, diphenhydramine, and haloperidol for agitation. Staff stated that antipsychotic medications should be included on the care plan and acknowledged that haloperidol, even in compound ointment form, should have been listed, but it was not on the resident's care plan. For another resident with diagnoses of senile degeneration of the brain, cerebral palsy, and hospice status, the care plan identified hospice services but did not include oxygen. The resident had an order for oxygen via nasal cannula to keep oxygen saturation above 90% as needed for shortness of breath and comfort measures, and the EHR documented oxygen use on multiple dates. During observation, the resident was seated in a wheelchair without oxygen while an oxygen concentrator was present in the room. In a separate review, a resident with end-stage renal disease, diabetes mellitus, a stage 3 sacral pressure ulcer, and neuromyopathy had an admission MDS indicating substantial to maximal assistance for all transfers, but the care plan stated the resident was an assist of 1 with a front wheel walker; a physician progress note and staff interview confirmed the resident required an EZ stand for transfers.
Oxygen therapy was not delivered or documented accurately for a resident
Penalty
Summary
The facility failed to ensure safe and accurate delivery of oxygen therapy for Resident #86, who had diagnoses including heart failure, hypertension, respiratory failure, pulmonary hypertension, and congestive heart failure with hypoxia. The care plan noted continuous oxygen via nasal cannula for CHF but did not include the ordered liter flow. The physician’s order directed oxygen at 4 liters via nasal cannula continuously with oxygen saturation checks twice daily, and the EMAR/ETAR reflected oxygen tubing and humidification changes and documented oxygen at 4 liters continuous through the morning of 8/19/25. Survey observations showed the resident with oxygen tubing in place while the room concentrator was off, oxygen off while the resident was sitting in a recliner, and later the oxygen set at just under 2 liters instead of the ordered amount. The tubing and humidification unit were also observed labeled with an earlier date than the EMAR indicated. Staff interviews revealed conflicting understanding of the oxygen order, including statements that the resident was off oxygen when out of the room, that the order had changed to PRN, and that the order was 4 liters PRN for dyspnea, while the EMAR still documented 4 liters continuous. The facility policy titled Oxygen Therapy and Portable Oxygen Tank lacked documentation on following doctor’s orders for proper liter flow, correctly reading liter flow on an oxygen concentrator, and documenting oxygen usage.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with 3 errors identified out of 27 observed medication administration opportunities for an error rate of 11.11%. The deficiency involved Resident #25 and Resident #66 during direct observation, clinical record review, staff interview, and policy review. The facility had a census of 95 residents. Resident #25 had diabetes and was ordered Lispro insulin by sliding scale before meals at 7:00 AM, 11:00 AM, and 4:00 PM. During observation, Staff E, RN, checked the resident’s blood glucose at 4:26 PM and later stated he planned to delay the insulin until after supper because of concerns about the resident’s food intake earlier in the day. The resident received dinner at 5:07 PM and ate 75 percent of the meal by 5:31 PM. Staff E administered 10 units of Lispro at 5:55 PM, but the record lacked documentation of a physician order or notification for delaying the insulin administration outside the ordered parameters. The DON stated staff should not use nursing judgment to change an insulin order and should contact the physician to change the order. Resident #66 had dysphagia and hypothyroidism and had orders for Omeprazole and Levothyroxine with specific timing requirements before meals and on an empty stomach. On observation, the resident was already eating breakfast when Staff F, LPN, prepared multiple medications, crushed tablets, emptied capsule contents into pudding, and administered the medications after breakfast had already begun. The LPN stated she believed the resident was supposed to take Omeprazole with other medications because of swallowing difficulty and confusion. The ADON stated staff had probably not requested removal of the before-meals instruction from the medication order. The record lacked documentation of physician orders or notification for the delayed administration of Omeprazole and Levothyroxine, and the facility policy required medications to be administered per physician orders and at the right time.
Delayed Insulin Administration
Penalty
Summary
The facility failed to administer insulin lispro before a meal as ordered for one resident with diabetes. The resident’s MDS dated 7/3/25 documented a diagnosis of diabetes and insulin use during the lookback period. The August 2025 MAR ordered lispro 100 mg/ml subcutaneously per sliding scale before meals, with scheduled administration times of 7:00 AM, 11:00 AM, and 4:00 PM. During observation on 8/19/25, Staff E, RN, checked the resident’s blood glucose at 4:26 PM and obtained a reading of 280, then stated he planned to hold the insulin until after supper because of concerns about the resident’s food intake earlier in the day. Continuous observation showed the resident received dinner at 5:07 PM and finished eating 75 percent of the meal by 5:31 PM. Staff E, RN, administered 10 units of lispro at 5:55 PM, after the meal was completed, rather than before the meal as ordered. Review of the clinical record found no physician order or documentation showing notification of the delay in insulin administration. The DON stated the nurse should not use nursing judgment to change an insulin order and should contact the physician to change the order, and reported that staff had recently been educated on this issue.
Failure to Maintain Hand Hygiene and Infection Control During Resident Care
Penalty
Summary
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 one resident reviewed for pressure ulcers. Resident #92 had an unhealed, unstageable pressure injury identified as a deep tissue injury, with the wound located on the right dorsum of the first metatarsal. The resident’s care plan noted pressure ulcer risk related to immobility and self-care deficits related to dementia, and directed staff to provide two staff for toilet use and transfers. During observation, staff performed toileting and transfer care for the resident, and one CNA cleansed the peri area and changed gloves without performing hand hygiene in between. The CNA then placed a new pull-up, pulled up the resident’s pants, and after the resident was transferred with a mechanical lift, grabbed the resident’s water pitcher by the handle and gave the resident a drink while still wearing gloves. During wound care, an LPN removed the old dressing and cleansed the wound without changing gloves, then changed gloves without hand hygiene in between. After finishing the dressing change, the LPN put away the cleanser in a cabinet while still wearing gloves, threw away trash, removed gloves, and then changed the trash without hand hygiene before carrying the trash to the door and using hand sanitizer while still holding the trash. The DON stated that hand hygiene should be performed between all glove changes and after removing a dirty dressing, and that contaminated items such as cabinets, sanitizer bottles, or water pitchers should be sanitized. The facility’s Infection Control Manual and hand-washing technique document stated staff should wash hands after handling contaminated sources such as equipment, dressings, secretions, and excretions, but did not include information on hand hygiene between changing gloves.
Failure to Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to offer the pneumococcal vaccine to 1 of 5 sampled residents reviewed for immunizations, Resident #25. The resident’s quarterly MDS, dated 7/3/25, identified an admission date of 7/12/24, age over [AGE], diagnoses of diabetes and dementia, and severe cognitive impairment. An informed consent for pneumococcal vaccine, dated 7/12/24, included authorization by the resident’s POA for the resident to receive the vaccine. On 8/20/25, review of Resident #25’s clinical record showed no documentation indicating whether the resident had ever received Pneumovax (PPSV23) or any pneumococcal conjugate vaccine, including Prevnar 20, Prevnar 21, or Vaxneuvance, per CDC guidelines. The DON stated the facility used a contracted pharmacy to track and oversee resident vaccines and maintained a spreadsheet of vaccines received, but she could not find evidence that Resident #25 had received the pneumococcal vaccine and was unsure why it had not been given. On 8/21/25, the DON confirmed the resident had not received the pneumococcal vaccine and contacted the pharmacy.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to provide adequate supervision and interventions for a resident who displayed exit-seeking behaviors, resulting in the resident leaving the building without staff knowledge. The resident, who had a severely impaired cognition with a BIMS score of 3 out of 15, was found outside in 29-degree Fahrenheit weather. The resident had a history of confusion and agitation, as documented in various notes, but the facility did not implement additional nursing supervision interventions despite these warning signs. The facility's elopement precautions policy required electronic door alarms to be activated at all times and for residents consistently seeking exits to have electronic monitoring devices. However, the facility did not identify the resident as at risk for elopement, and the resident was able to exit the building independently. Staff interviews revealed that the door did not require a code to exit, and the alarm did not sound when the door was opened, allowing the resident to leave unnoticed. Observations during a facility tour showed that several doors did not require a code to exit and did not alarm upon exit, providing residents with the ability to leave the building without staff knowledge. This lack of security measures and supervision led to the resident's unsupervised exit, posing an immediate jeopardy to the health, safety, and security of the resident and other cognitively impaired residents in the facility.
Removal Plan
- Wanderguard placed on Resident #1.
- Staff education regarding elopement policy, elopement drills, significant change assessments, response to door alarms.
- Elopement assessments on all residents with a Brief Interview for Mental (BIMS) score less than 11.
- Sign placed on exit doors for families as reminder to not assist someone out the door and to notify team members.
- Alarms activated on egress doors in Overijessel (OV) and Utrecht (UT) households.
- Barrel lock installed on patio door connecting OV/UT.
- Remote notification alarm installed between the long-term care area and the assisted living area.
- Door lock installed on Gelderland household dining room door.
Inaccurate Documentation of Resident's Code Status
Penalty
Summary
The facility failed to accurately document the code status for Resident #147, who had diagnoses including multiple sclerosis, thyroid disorder, and a left fibula fracture. The Minimum Data Set (MDS) assessment and the Care Plan indicated that the resident's advance directives should be routinely reviewed and updated. However, discrepancies were found between the electronic health record (EHR) and the Iowa Physician's Orders for Scope of Treatment (IPOST) form. The EHR initially listed the resident as a Full Code, while the IPOST signed by the physician indicated a Do Not Resuscitate (DNR) status. This inconsistency was not corrected in the EHR until several days later. Interviews with staff revealed a breakdown in the process of updating the resident's code status in the EHR. The Social Worker (SW) was responsible for obtaining the resident's or representative's signature on the IPOST and updating the EHR, but the code status was not accurately reflected in the system. Staff members, including Licensed Practical Nurses (LPNs) and Registered Nurses (RNs), relied on the EHR to verify code status, leading to potential confusion. The Director of Nursing acknowledged ongoing efforts to improve the process, and the Clinical Quality RN Specialist admitted to not comparing IPOST information with the EHR to ensure consistency.
Failure to Implement Nutritional Interventions for Resident
Penalty
Summary
The facility failed to evaluate and implement necessary nutritional interventions for Resident #72, who was experiencing ongoing weight loss and poor intake at meals. Despite the resident's cognitive impairments and diagnoses, including Alzheimer's and Parkinson's disease, the care plan was not updated to reflect current interventions for weight loss. The care plan included goals for food intake and various interventions, but none specifically addressed the resident's low food intake since July 2023. The facility's records showed a significant weight loss trend for Resident #72, with weights dropping from 144.8 lbs in January 2024 to 127.8 lbs in September 2024. Despite this, the Registered Dietitian (RD) did not document any nutritional interventions or rationale for the lack of interventions, even when significant weight loss was identified. The RD noted that weight loss and other health issues might be expected as the disease progresses, but no specific actions were taken to address the resident's nutritional needs. Interviews with staff revealed a lack of awareness and documentation regarding the resident's dietary needs and family preferences. The Director of Dining and the RD discussed weight loss and potential interventions in weekly meetings, but no formal records were kept, and no interventions were implemented for Resident #72. The facility's policy required nutritional interventions for significant weight loss, but this was not followed, leading to a deficiency in the care provided to the resident.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions (EBP) and infection control practices, leading to potential infection risks for two residents. One resident, who was readmitted from the hospital with a methicillin susceptible staphylococcus aureus (MSSA) infection and an epidural abscess, did not receive proper infection control measures during intravenous (IV) medication administration. The Licensed Practical Nurse (LPN) involved did not wear a gown while handling the resident's peripherally inserted central catheter (PICC) line, despite the presence of the Director of Nursing (DON) in the room. The facility lacked a specific policy for IV medication administration, and staff were not consistently informed about the necessity of wearing gowns and gloves when dealing with PICC lines. Another deficiency was observed during the administration of tube feeding and medications for a resident. The Registered Nurse (RN) involved did not follow proper hygiene protocols, as the gastric-tube extension was placed in the bathroom sink and rinsed alongside other used supplies, increasing the risk of cross-contamination. The Director of Nursing acknowledged that the g-tube extension should have been rinsed first to minimize contamination risks. Additionally, during lunch preparation and service, a cook failed to perform hand hygiene after handling soiled equipment and before engaging in food preparation. This lapse in hand hygiene was noted by the Director of Dining, who was present during the meal preparation. The facility did not have a separate hand hygiene policy for dietary staff, relying instead on the general infection control manual, which contributed to the oversight.
Failure to Provide Required Bathing Assistance
Penalty
Summary
The facility failed to ensure a resident had at least 2 baths/showers per week. Resident #1, who had intact cognition and required physical assistance with bathing due to a stroke, osteoporosis, and anxiety, was documented to have received showers/baths only 3 times over a one-month period. The resident's care plan directed staff to provide assistance with bathing twice a week. The Clinical Quality Specialist confirmed the deficiency, acknowledging that the facility's standard is to provide a bath or shower a minimum of 2 times a week and to document any refusals. However, the facility did not have a specific policy related to baths/showers, relying instead on standards of care.
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What surveyors actually found near you
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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 Pella
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accura Healthcare Of Knoxville, Llc | 11.4 mi | ★★★★★ | 10 | 1 |
| West Ridge Specialty Care | 12.9 mi | ★★★★★ | 3 | 0 |
| Oskaloosa Care Center | 15.5 mi | ★★★★★ | 11 | 1 |
| Crystal Heights Care Center | 15.9 mi | ★★★★★ | 1 | 0 |
| Northern Mahaska Specialty Care | 16 mi | ★★★★★ | 9 | 0 |
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