Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cottage Grove Post Acute during CMS and state inspections, most recent first.
Two residents did not receive their prescribed pain medications due to the facility running out of stock and failing to reorder in a timely manner. One resident, on hospice care and with a history of chronic pain, missed multiple doses of morphine, developed opioid withdrawal symptoms, and required hospitalization. Another resident with chronic joint pain missed several doses of Lyrica, resulting in severe pain that was not relieved by non-pharmacological interventions. Staff interviews confirmed ongoing issues with medication reordering and communication with providers.
Several residents, including those with reduced mobility, kidney disease, Multiple Sclerosis, and schizoaffective disorder, did not have their required MDS assessments completed on time. The LPN MDS Coordinator reported being behind due to workload, resulting in overdue Annual, Quarterly, and Discharge MDS assessments. Facility leadership confirmed that timely completion of MDS assessments is the expected standard.
Surveyors found that the facility did not consistently provide palatable or appetizing meals, as evidenced by overcooked pasta, bland vegetables, and flavorless bread and meatballs. Two residents reported dissatisfaction with the food, describing it as bland, sometimes cold, and unappealing. The Dietary Manager and Administrator confirmed the issues after sampling the meal.
Staff failed to prevent a resident from handling PPE supplies without sanitization, allowed soiled items to be placed near clean water and ice supplies, and did not implement enhanced barrier precautions or proper signage for a resident with open wounds. Multiple staff provided wound care without PPE, and staff were unaware of required precautions due to inconsistent care plan updates.
A resident with heart and kidney disease was transferred to the hospital for symptoms such as nausea, diarrhea, malaise, cold sweats, and dizziness, but the physician was not notified of the transfer. Review of records and staff interviews confirmed the lack of physician notification.
A resident with anxiety and reduced mobility reported missing six packs of cigarettes from a locked storage box at the nurses' station. Facility policy required smoking materials to be stored in these boxes, but it was found that the keys could open multiple boxes and the drawer was not consistently locked. Staff confirmed the security issues, and the facility lacked adequate tracking and safeguarding of residents' property, resulting in the loss.
A resident with heart and kidney disease was transferred to the hospital for symptoms such as nausea, diarrhea, malaise, cold sweats, and dizziness, but the facility did not provide the receiving provider with the responsible practitioner's contact information, advance directive details, or medication information prior to transfer. The DNS could not produce documentation confirming this information was communicated.
A resident with heart and kidney disease was discharged from hospice, but staff did not complete the required Significant Change MDS assessment within the mandated timeframe. The LPN/MDS Coordinator did not discuss the change with the resident or perform the assessment, and the DNS confirmed the oversight.
A resident admitted with multiple sclerosis and a Stage 3 pressure ulcer did not have a baseline care plan addressing wound care needs completed within 48 hours of admission. Staff confirmed that a care plan should have been initiated upon admission, but review of records and interviews revealed this was not done.
Two residents did not receive care as ordered by their physicians, including missed weight monitoring for a resident with heart failure and missed doses of Austedo for a resident with schizoaffective disorder due to medication unavailability. Documentation was inconsistent, and staff did not always notify the PCP promptly when issues arose.
A resident's pain medication was misappropriated due to a failure in following the facility's policy on handling controlled substances. An LPN received a package of narcotics but did not verify its contents and left it unattended. Another LPN later discovered the medication was missing, and the facility acknowledged the policy was not followed.
The facility failed to store narcotic pain medications safely, as required by policy, leading to the misappropriation of a medication card containing oxycodone tablets. Narcotic medications were left unattended and visible behind the nursing station, contrary to the policy of storing them in locked compartments. Staff interviews confirmed the lapse in procedure, and the incident was reported to law enforcement.
Failure to Provide Timely Pain Medication Results in Unmanaged Pain and Hospitalization
Penalty
Summary
The facility failed to provide appropriate pain management for two residents who required such services, resulting in significant lapses in care. One resident, who was cognitively intact and had a history of heart and kidney disease, was admitted to hospice and had physician orders for scheduled and PRN morphine for pain and shortness of breath. The facility ran out of the resident's prescribed morphine, and staff did not reorder the medication in a timely manner. As a result, the resident went several days without receiving the narcotic pain medication, experienced unmanaged pain, and developed symptoms consistent with opioid withdrawal, including nausea, vomiting, diarrhea, cold sweats, and elevated blood pressure. The resident was ultimately transferred to the hospital for evaluation and treatment. Documentation confirmed that seven doses of morphine were missed due to the medication being unavailable or not administered, and staff interviews revealed ongoing issues with medication reordering processes and communication with the on-call provider. Another resident with polyosteoarthritis had a physician order for Lyrica twice daily for pain management. The facility ran out of Lyrica, and the resident did not receive the medication for several doses over multiple days. During this period, the resident's pain levels fluctuated from 0/10 to 10/10, and non-pharmacological interventions were attempted but were not effective. Staff acknowledged that there was no designated person responsible for reordering medications, leading to frequent medication shortages, especially over weekends. The resident reported experiencing constant pain and stated that running out of pain medication was a recurring issue. In both cases, the facility's failure to maintain adequate medication supplies and ensure timely reordering directly resulted in residents experiencing unmanaged pain and, in one case, opioid withdrawal and hospitalization. Staff interviews and documentation confirmed that the medication management system was ineffective, with lapses in communication and follow-through on medication orders.
Failure to Complete Timely MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete Minimum Data Set (MDS) assessments in a timely manner for four out of eight sampled residents. For one resident with reduced mobility and muscle wasting, the Discharge Return Not Anticipated MDS assessment was overdue by nine days. The MDS Coordinator confirmed being behind on work due to a busy schedule, resulting in the late assessment. Another resident with kidney disease and heart failure had an Annual MDS assessment overdue by thirteen days, with the same explanation provided by the MDS Coordinator. Additionally, a resident with Multiple Sclerosis had a Quarterly MDS assessment completed three days late. Another resident with schizoaffective disorder had both an Annual MDS and a Quarterly MDS completed late, with the Annual MDS overdue by over two weeks and the Quarterly MDS overdue by several days. The MDS Coordinator acknowledged the delays in all cases, and facility leadership confirmed that the expectation was for MDS assessments to be completed on time.
Failure to Provide Palatable and Appetizing Food
Penalty
Summary
The facility failed to provide palatable, attractive, and appetizing food to residents, as evidenced by observations, interviews, and test tray sampling. During a lunch meal service, the spaghetti noodles were found to be mushy, soft, and overcooked, the herb green beans tasted metallic and bland, and the garlic bread stick was doughy with no garlic flavor. The meat sauce was described as flavorful, but the meatball lacked flavor. The Dietary Manager confirmed these findings after sampling the meal, noting the pasta was soft, the green beans lacked taste, and the bread stick may have softened while sitting in the steam table. The Administrator acknowledged that overcooked pasta should not be a regular occurrence and expected the menu items to have the appropriate flavors. Two residents expressed dissatisfaction with the food. One resident, with a diagnosis of quadriplegia, reported that the vegetables were overcooked and bland. Another resident, with a history of depression, stated the food was terrible, sometimes cold, and the meat was occasionally too tough. This resident also reported that the spaghetti and meatball served for lunch were bland and needed more seasoning. These findings were consistent with the test tray results and staff observations, indicating a failure to consistently provide palatable and appetizing meals as required.
Failure to Follow Infection Control Standards and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control standards in multiple instances. On one hall, a resident was observed handling various items in a PPE cart, including masks and a stethoscope, for several minutes without staff intervention or subsequent sanitization of the cart. Although a staff member was present during the incident, no immediate action was taken to prevent the resident from touching the items or to clean the cart afterward. Staff later acknowledged that this did not align with infection control protocols. Additionally, on the same hall, a water pitcher cart was found near a room under enhanced barrier precautions (EBP) with an uncovered ice scoop and a soiled cup placed next to clean items, such as gloves and straws. Staff admitted that it was difficult to prevent residents from placing dirty items on the cart and that the presence of soiled items was not in line with best practices. Furthermore, a resident with open wounds requiring daily and twice-daily wound care did not have appropriate EBP signage posted outside their room, and multiple staff members provided care without donning PPE. Staff involved were unaware of the need for precautions and confirmed that care plans and signage were not consistently updated.
Failure to Notify Physician of Resident Hospitalization
Penalty
Summary
The facility failed to notify a resident's physician when the resident was discharged to the hospital. The resident, who had a history of heart disease and kidney disease, was admitted to the facility in October 2024. On June 8, 2025, the resident was sent to the hospital due to symptoms including nausea, diarrhea, general malaise, cold sweats, and dizziness. A review of the clinical record showed no documentation that the physician was informed of the hospital transfer. Interviews with facility staff confirmed that the physician was not notified at the time of the resident's hospitalization.
Failure to Safeguard Resident Personal Property
Penalty
Summary
A resident with anxiety and reduced mobility, who was cognitively intact, reported the loss of six packs of cigarettes from a locked storage box at the nurses' station. Facility policy required residents to store smoking materials in these locked boxes, with residents keeping a key and staff assisting with access. However, it was observed that the keys distributed to residents could open multiple boxes, compromising the security of personal property. The resident expressed concerns about the effectiveness of the locks and declined to store cigarettes at the nurses' station due to this issue. Staff interviews and observations confirmed that the drawer containing the cigarette storage boxes was not consistently kept locked, and a master key capable of opening multiple boxes was accessible in the same drawer. The facility's process for tracking and safeguarding residents' smoking materials was insufficient, as evidenced by the missing cigarettes and the lack of evidence regarding their existence. These lapses in securing residents' property led to the deficiency cited in the report.
Failure to Communicate Required Information During Hospital Transfer
Penalty
Summary
The facility failed to ensure that appropriate information was communicated to the receiving health care institution or provider prior to the transfer of a resident to the hospital. Specifically, for a resident admitted with heart disease and kidney disease, there was no evidence in the clinical record that the facility provided the contact information of the practitioner responsible for the resident's care, advance directive information, or details regarding medications (including when last received) before the resident was sent to the hospital for symptoms including nausea, diarrhea, general malaise, cold sweats, and dizziness. During an interview, the Director of Nursing Services was unable to provide documentation confirming that this information was given to the hospital prior to the resident's transfer.
Failure to Complete Significant Change MDS Assessment After Hospice Discharge
Penalty
Summary
The facility failed to complete a Significant Change MDS assessment (SCSA) within the required 14 days after a significant change in condition for a resident who was discharged from hospice care. The resident, admitted with heart and kidney disease, was noted to be cognitively intact and on hospice as of the last quarterly MDS. Staff confirmed that the resident graduated from hospice, but the MDS Coordinator did not discuss this change with the resident or complete the required SCSA. The Director of Nursing also acknowledged that the SCSA was not completed following the resident's discharge from hospice.
Failure to Initiate Baseline Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for a resident with a Stage 3 pressure ulcer. The resident, who was admitted with multiple sclerosis and a Stage 3 pressure ulcer, did not have a baseline care plan addressing wound care needs documented in the care plan review. Observations confirmed the presence of the pressure ulcer, and staff interviews acknowledged that a care plan focused on the wound should have been initiated upon admission but was not completed. Record review and staff statements confirmed the absence of a timely baseline care plan for the resident's pressure ulcer.
Failure to Follow Physician Orders and Ensure Medication Availability
Penalty
Summary
The facility failed to follow physician orders and ensure proper documentation for two residents with significant medical needs. One resident with hypertensive heart disease and heart failure had physician orders for regular weight monitoring, including daily and weekly weights, to support cardiac management. However, the resident's weight was only documented a fraction of the required times, with inconsistent use of codes such as 'NA' and 'code six' without clear definitions. Staff interviews confirmed that weights or refusals were not consistently documented as expected, and there was a lack of clarity regarding the documentation process. Another resident with schizoaffective disorder and drug-induced dyskinesia did not receive prescribed doses of Austedo on multiple occasions due to the medication being unavailable. Documentation showed that the pharmacy was contacted after several missed doses, and there were delays in notifying the primary care provider (PCP) about the missed medication. The resident reported feeling the effects of missing the medication, and staff acknowledged that medications should be ordered in advance to prevent running out, with prompt notification to the PCP when medications are unavailable.
Misappropriation of Resident's Pain Medication
Penalty
Summary
The facility failed to ensure the proper handling and documentation of controlled substances, leading to the misappropriation of a resident's pain medication. A resident, who was admitted with a leg fracture, was supposed to receive a card of oxycodone containing 14 tablets. The medication was delivered to the facility along with other narcotics, but it was not properly checked or secured. Staff 4, an LPN, received the package but did not verify its contents and left it unattended at the nursing station. Later, Staff 3, another LPN, discovered that the resident's medication was missing. Interviews revealed that Staff 4 did not maintain direct observation of the medication package from the time it arrived until it was discovered missing. Staff 3, who was on break when the medications were delivered, was not informed about the delivery and only noticed the package later. The facility's policy on ordering and receiving controlled medications was not followed, as acknowledged by Staff 1. The incident was reported to law enforcement, but the facility could not substantiate the misappropriation at the time of the investigation.
Improper Storage of Narcotic Medications
Penalty
Summary
The facility failed to store narcotic pain medications in a safe manner, which placed residents at risk for misappropriation of medications. The facility's Controlled Medication Storage policy required narcotic pain medication to be maintained in separately locked, permanently affixed compartments. However, on a specific date, narcotic medications were delivered to the facility and were not stored according to this policy. Instead, the medications were placed behind the nursing station, visible to anyone, and not under direct observation. This lapse in procedure led to the discovery that a medication card of 14 tablets of oxycodone for a resident was missing. Interviews with staff revealed that the narcotic medications were received by an LPN who did not check the contents of the package and left it unattended. Another LPN noticed the package sitting on a computer at the nurse's station after returning from a break. The facility acknowledged that the policy was not followed, leading to the improper storage of narcotic pain medications. The incident was reported, and law enforcement was notified, but the resident did not miss any doses of pain medication.
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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 Cottage Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Creswell Post Acute | 9.2 mi | ★★★★★ | 29 | 0 |
| Creekside Health And Rehabilitation Of Cascadia | 16.4 mi | ★★★★★ | 5 | 0 |
| Cascade Manor | 16.8 mi | ★★★★★ | 4 | 0 |
| South Hills Rehabilitation Center | 16.9 mi | ★★★★★ | 6 | 0 |
| Hillside Heights Rehabilitation Center | 17 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.