The Cottage Extended Care

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600May 30, 2025

  On 05/29/25 at 4:40 p.m., the OSDH was notified and verified the existence of a past non-compliance immediate jeopardy (IJ) situation related to the facility's failure to ensure wound care was completed as ordered. On 05/29/25 at 4:47 p.m., the administrator was notified of the immediate jeopardy (IJ) situation. The administrator was provided the IJ template Based on record review and interview, the facility failed to ensure a resident had wound care completed as ordered for 1 (#1) of 3 sampled residents reviewed for wound care. […]

• No harm, potential for more than minimal, patternF690Nov 29, 2023

  Based on record review and interview, the facility failed to ensure physician's orders were obtained for catheter care for one (#1) of four residents reviewed for catheters. The DON identified 16 residents with catheters. Findings: Resident #1 had diagnoses which included urinary retention and chronic kidney disease. Resident #1's Significant Change in Status Assessment, dated 05/25/23, documented the resident was moderately impaired for daily decision making. A physician order, dated 09/22/23, documented Install Foley Catheter for Urinary Retention. On 11/28/23 at 1:05 p.m., LPN #1 stated that all residents with catheters should have an order for catheter care every shift and it should be documented in the TAR. […]

• No harm, potential for more than minimal, patternF550Dec 2, 2021

  Based on observation, interview, and record review, the facility failed to ensure dignity was maintained by covering urinary drainage bags with dignity bags for two (#32 and #61) of two residents reviewed for dignity. The DON identified 14 residents who required urinary drainage bags. Findings: 1. Resident (Res) #32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Care Plan updated 04/20/21, read in parts, .Be sure cath bag is covered with dignity bag . A quarterly assessment, dated 10/13/21, documented the resident was severely impaired with cognition, was dependent on staff for activities of daily living, required an indwelling urinary catheter and was incontinent of bowel. […]

• No harm, potential for more than minimal, patternF570Dec 2, 2021

  Based on interview and record review, the facility failed to ensure the facility surety bond was in an amount to secure all personal funds of residents who deposited with the facility. The Administrator identified ten residents who had personal funds with the facility. Findings: On 12/01/21 at 11:00 a.m.,, the business office manager provided a trust fund statement for November 2021 in the amount of $73, 319.39. On 12/01/21 at 1:00 p.m., the Administrator provided a Certificate of Liability Insurance form, dated 09/20/21- 09/20/22, which documented the resident fund bond was $25,000. The Administrator reported they were unaware the surety bond did not cover liability of the resident trust fund.

• No harm, potential for more than minimal, patternF685Dec 2, 2021

  Based on observation, interview, and record review, the facility failed to ensure eye glasses were repaired for one resident (#42) of one sampled for vision. The DON identified 30 residents who required eye glasses. Findings: Resident (Res) #42 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual assessment, dated 10/22/21, documented Res #42 was severely impaired in cognition and required moderate assistance with activities of daily living. A care plan, dated 10/30/21, documented in part I have impaired visual function. I will use appropriate visual devices glasses to promote participation in activities of daily living and other activities. Ensure appropriate visual aids, are available to support by participation in activities . […]