Stone Cottage Care Center

In the surveyor’s words

From the most serious findings on record at Stone Cottage Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF609Nov 30, 2023

  Based on resident interview, staff interview, record review, facility investigation review and facility policy review the facility failed to report an allegation of abuse for 1 of 3 residents reviewed for abuse. The facility staff failed to report an allegation of abuse that occurred on 11/10/23 which alleged staff member pushed and threatened Resident #3. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of November 10, 2023 on November 27, 2023 at 3:45 PM. The facility staff removed the Immediate Jeopardy on November 28, 2023 at 3:10 PM by implementing the following actions: a. Licensed Practical Nurse (LPN) Staff A was suspended on 11/20/23 b. All staff education began on 11/27/23 by the Administrator c. […]

• Immediate jeopardy, isolatedF684Dec 29, 2022

  Based on clinical record reviews and staff interviews, the facility failed to complete a comprehensive assessment on a resident with a persistent and excruciating headache, motor skill decline, and a change in mental status for one of four residents reviewed (Resident #1). Due to the lack of a comprehensive assessment for Resident #1, this resulted in an Immediate Jeopardy incident. On December 7, 2022 at 3:00 PM, the Iowa Department of Inspections and Appeals notified the facility of the Immediate Jeopardy. The facility reported a census of 24. Findings include: According to the Minimum Data Set (MDS) assessment tool with an Assessment Reference Date of 10/20/22, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. […]

• Actual harm, isolatedF689Nov 5, 2025

  Based on observation, clinical record review, and staff and resident responsible party interviews, the facility failed to provide adequate supervision and staff assistance to residents to prevent injuries from falls, for 1 of 4 residents with fall histories reviewed (Resident #4). The facility's failure to provide the appropriate supervision and assistance resulted in Resident #4's hospitalization in a hospital Intensive Care Unit with injuries that included hemothorax, fractured 6th through 10th right ribs, displaced right shoulder and compression fracture of the 10th thoracic vertebrae that resulted from an unwitnessed fall. The facility reported a census of 34 residents. […]

• Actual harm, isolatedF689Sep 25, 2023

  Based on clinical record review and staff interviews, the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents. (Resident #2) The facility reported census was 26. Findings include: The Quarterly Minimum Data Set (MDS) with a reference date of 8/24/23, documented that Resident #2 had impaired long and short term memory deficits and a severely impaired cognitive status. Resident #2 required extensive assistance of two staff members with transfers, mobility, dressing, toilet use and personal hygiene needs. […]

• No harm, potential for more than minimal, widespreadF801Sep 4, 2025

  Based on professional certification review and staff interviews, the facility failed to employ a qualified person to serve as the Dietary Manager in the absence of a full-time dietitian. The facility reported a census of 30 residents. Findings include:As of 9/2/25, the facility lacked documentation that Staff E Dietary Manager(DM) completed the Certified Dietary Manager(CDM) course.On 9/3/25 at 11:00 a.m., Staff E stated she did not complete the CDM course. She stated she started in August 2025 and would finish in December 2025. On 9/4/25 at 12:27 p.m., the Administrator stated the DM should be certified. She stated she was enrolled last year but did not finish and was currently in the course again. She stated she did not have a policy regarding DM qualifications.