The Cottages

In the surveyor’s words

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

• Immediate jeopardy, patternF689Feb 24, 2025

  Based on observation, clinical record review, policy review, and staff interviews, the facility failed to provide additional interventions, and supervision after Resident#1 displayed exit seeking behaviors. The facility also failed to secured the facility's exterior doors so that cognitively impaired residents could not leave the building without staff knowledge. This resulted in Resident #1 leaving the building without the staff's knowledge in 29 degree Fahrenheit weather. The staff only realized Resident #1 had left the building when a visitor found Resident #1 lying on the ground. […]

• Actual harm, isolatedF689Jun 4, 2026

  Based on clinical record review, staff interviews, resident interview and policy review the facility failed to ensure resident safety when ambulated and when transferred to a chair without a gait belt for 1 of 3 residents reviewed (Resident #2). The fall resulted in a hip fracture that required surgery. The facility reported a census of 90 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] reflected Resident #2 activity prior to fall documented used a walker, required substantial to maximal assist with sit to stand and lying to sit needed partial to moderate assistance, to lift, hold or support trunk or limb. Resident #2 required supervision or touch assist when walking up to 10 -50 feet. […]

• Actual harm, isolatedF689Aug 25, 2025

  Based on clinical record review, policy review, and staff interviews, the facility failed to create and implement interventions to prevent a fall which resulted in an ER visit for 1 of 3 residents reviewed for falls(Resident #20). The facility reported a census of 95 residents. Findings include:The Minimum Data Set (MDS) assessment tool, dated 5/20/25, listed diagnoses for Resident #20 which included fracture, non-Alzheimer's dementia, and arthritis. The MDS stated the resident sustained a fracture related to a fall in the 6 months prior to admission and stated the resident required partial/moderate assistance for chair and toilet transfers. The MDS listed a Brief Interview for Mental Status (BIMS) score as 11 out of 15, indicating moderately impaired cognition. […]

• No harm, potential for more than minimal, patternF725Jun 29, 2023

  Based on facility record review, family interview and staff interviews , the facility failed to answer the residents' call lights in less than 15 minutes for 4 of 4 residents reviewed (Resident #30, 42, 57, 75). The facility reported a census of 74 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] of Resident #30 identified a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. The MDS revealed the resident required extensive assistance of two staff members for bed mobility, transfers and toileting. […]

• No harm, potential for more than minimal, isolatedF550Jun 4, 2026

  Based on clinical record review, policy review, staff interviews, resident and family interview the facility failed to provide dignity and respectful treatment for 1 of 3 residents reviewed. The facility reported a census of 90. Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed required assistance with sit to lye or sit to stand or transfer to chair or toilet. Resident #1 required partial to moderate assistance of staff for lifts, holds, or support of trunk or limb and was dependent on toileting hygiene. The Brief Interview for Mental Status (BIMS) exam Coded a score of 13 out of 15 indicating intact cognition. […]