Cottage Grove Place

In the surveyor’s words

From the most serious findings on record at Cottage Grove Place, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 14, 2026

  Based on clinical record review, staff interview, observation, fire department and police reports, ambulance reports, employee file review, and facility record review, the facility failed to utilize a lap and shoulder seatbelt restraint prior to transporting a resident in a facility van for 1 of 3 residents reviewed (Resident #1). On [DATE], during transport from a doctor's appointment, the facility van driver failed to secure a lap and shoulder seatbelt restraint for Resident #1, who was seated in a secured wheelchair in the back of a transport van. As a result, Resident #1 flew forward out of the wheelchair over a folded middle row seat when the driver swerved and braked to avoid another vehicle. […]

• Actual harm, isolatedF689Jan 6, 2026

  Based on observation, clinical record review, and staff interviews the facility failed to provide appropriate supervision to prevent a fall that resulted in fracture of the resident's right scapula (shoulder blade) and pain for one of three residents reviewed (Resident #1). The facility reported a census of 55 residents. Findings include:Resident #1 admitted to the facility on [DATE] from Assisted Living after she had a fall that resulted in a fracture of the left humerus (upper arm). […]

• No harm, potential for more than minimal, patternF812Jun 25, 2026

  Based on observation, interview, and policy review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions. Reviewed 1 of 3 dining areas. Facility reported a census of 56.Findings include:Observed on 06/22/2026 at 9:23 AM during the initial tour of the kitchen, the walk-in cooler revealed three containers of expired low-fat buttermilk stored on the top shelf on the right-hand side. The expiration date on the containers was 6/19/2026. Additionally, an empty cardboard box with water damage on the back edge was observed on the floor underneath the shelves. […]

• No harm, potential for more than minimal, patternF802May 1, 2025

  Based on observations, staff interviews, and policy review the facility failed to provide sufficient dietary staff with the appropriate skills and competencies to safely and effectively provide food service to the facility residents. The facility reported a census of 59 residents. Findings Include: During observation of the facility puree process with Staff A, [NAME] on 04/29/25 at 10:30 am revealed the staff member lacked training and knowledge of the puree process. Staff A lacked instruction on how to complete the puree process and ensure puree diet residents get the same portions as regular diets. Staff A was uncertain how to measure out the puree content, did not know portion sizes and advised they serve pudding or ice cream instead of the dessert of the day. […]

• No harm, potential for more than minimal, patternF812May 1, 2025

  Based on observation, staff interviews, facility documentation, and policy review, facility staff failed to ensure the internal temperature of food provided to the residents was cooked to the proper internal temperature and failed to document internal temperatures in the log book. The facility reported a census of 59 residents. Findings Include: After observation of the facility meal process with Staff A, [NAME] on 04/29/25 at approximately 11:50 am Staff A failed to log food temperatures into the log book. Staff A advised all food temperatures where taken prior to meal service and all temperatures met required internal temperatures and it was an oversight not to log the temperatures. […]