Cottage Grove Post Acute

In the surveyor’s words

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

• Actual harm, isolatedF697Jun 27, 2025

  Based on observation, interview, and record review it was determined the facility failed to provide appropriate pain management for 2 of 2 sampled residents (#s 33 and 39) reviewed for pain management. This failure resulted in Resident 39 not receiving her/his scheduled narcotic pain medications for three days which caused the resident to suffer from narcotic withdrawal, increased pain, and an avoidable hospitalization. This placed residents at risk for narcotic withdrawal and increased pain. Findings include: 1. Resident 39 admitted to the facility in 10/2024 with diagnoses including heart disease and kidney disease. Resident 39's 4/14/25 Quarterly MDS indicated the resident was cognitively intact. Resident 39 received scheduled pain medication and PRN pain medications. […]

• Actual harm, isolatedF686Nov 18, 2022

  Based on observation, interview and record review it was determined the facility failed to prevent the development of a pressure ulcer, failed to ensure accurate and completed wound assessments, failed to care plan the pressure ulcer and failed to demonstrate the resident's clinical condition made the development of a pressure ulcer unavoidable for 1 of 1 sampled resident (#35) reviewed for pressure ulcers. This resulted in Resident 35 developing an unstageable (full thickness skin preventing view of the depth of the wound) pressure ulcer. […]

• No harm, potential for more than minimal, widespreadF801Mar 8, 2024

  Based on interview and record review it was determine the facility failed to ensure the dietary manager had current certification for 1 of 1 kitchen reviewed. This placed residents at risk for unmet dietary needs. Finding include: On [DATE] at 10:23 AM and 3:09 PM Staff 26 (Dietary Manager) was requested to produce her Dietary Manager certification. Staff 26 stated she believed her certification as a Dietary Manager expired in ,d+[DATE] and she was unable to located her certificate. On [DATE] at 8:30 AM Staff 1 (Administrator) acknowledged Staff 26's certification was expired.

• No harm, potential for more than minimal, patternF636Jun 27, 2025

  Based on interview and record review it was determined the facility failed to complete timely MDS assessments for 4 of 8 sampled residents (#s 20, 21, 32, and 33) reviewed for MDS and unnecessary medications. This placed residents at risk for unassessed needs. Findings include: 1. Resident 20 was admitted to the facility in 1/2025 with diagnoses including reduced mobility and muscle wasting. A review of Resident 20's clinical record revealed her/his Discharge Return Not Anticipated MDS assessment was in progress and overdue by nine days on 6/24/25. On 6/26/25 at 9:59 AM, Staff 5 (MDS Coordinator) stated she was very busy for the last two to three weeks and was behind on her work and confirmed Resident 20's MDS was late. […]

• No harm, potential for more than minimal, patternF804Jun 27, 2025

  Based on observation, interview, and record review it was determined the facility failed to provide palatable food to 1 of 1 kitchen and 2 of 4 (#s 4 and 33) residents reviewed for food and kitchen tasks. This placed residents at risk for weight loss and reduced quality of life. Findings include: 1. A review of the 6/25/25 lunch menu revealed the facility was to provide: spaghetti with meatballs, herb green beans, and garlic bread sticks. On 6/25/25 at 11:44 AM kitchen meal service was observed. Pasta, meat sauce, garlic bread sticks, and green beans were observed to be served from the steam table. Pasta was observed to be served with tongs, appeared overcooked, and broke apart as it was served. […]