The Cottages: Medication Delays Force Resident Exit - IA
Resident 99 arrived at the 95-bed facility on April 25 from a hospital with orders for three medications: Alrex eye drops for allergies, Pregabalin for nerve pain, and Duloxetine for depression. Her medical assessment showed intact cognition with a score of 14 out of 15 on mental status testing, along with diagnoses of rheumatoid arthritis and weakness.
None of the medications arrived as scheduled.
Progress notes documented that her Alrex eye drops were unavailable at 5:53 p.m. on April 25, then again at 9:07 p.m. The next day brought more of the same: missing eye drops noted at 9:33 a.m., 11:12 a.m., 6:02 p.m., and 8:41 p.m. Staff continued documenting the unavailable medication through April 27 at 10:45 a.m.
Her Pregabalin, prescribed three times daily for nerve pain, was first noted as missing at 2:18 p.m. on April 25. Staff documented its absence again on April 26 at 9:11 a.m. and April 27 at 11:05 a.m.
The antidepressant Duloxetine was marked unavailable at 2:17 p.m. on April 25.
Medication administration records showed the pattern clearly. Doses that should have been given carried no staff initials or checkmarks. Instead, entries were marked with a "9" — the facility's code referring readers to progress notes that explained the medications simply weren't there.
For the eye drops alone, eight scheduled doses went unadministered between April 25 and April 27. The nerve pain medication missed five doses during the same period.
The facility's pharmacy workflow policy outlined the standard process: nurses fax signed orders to the pharmacy, which processes and delivers medications. But the policy contained a critical gap. It provided no guidance for what staff should do when medications failed to arrive.
Progress notes revealed no documented attempts by facility staff to contact the pharmacy about the missing medications. No calls for expedited delivery. No follow-up with providers for alternative orders.
On April 27 at 7:00 p.m., two days after admission, the resident departed with her spouse against medical advice.
Staff interviews three months later revealed confusion about proper procedures. On August 20, Staff A, a registered nurse, told inspectors she had received education about calling providers to obtain medications. "It wasn't appropriate to just wait for the pharmacy," she said, acknowledging the facility had "trouble getting her Pregabalin."
The Director of Nursing explained that staff had options when medications didn't arrive. They could call for emergency delivery from the pharmacy. If residents arrived without orders, staff should contact providers for new prescriptions or instructions to hold the medication.
These procedures weren't followed for Resident 99.
The inspection found that facility policy failed to address medication delays, leaving staff without clear direction when the standard workflow broke down. The result was a cognitively intact resident with multiple medical conditions going without prescribed treatments while staff documented the problem but took no corrective action.
Federal inspectors classified the violation as causing minimal harm with potential for actual harm, affecting few residents. But for Resident 99, the impact was immediate and personal — a hospital discharge that should have led to continued care instead became a three-day period without essential medications, ending with her decision to leave the facility entirely.
The case highlighted a fundamental breakdown in pharmaceutical services at The Cottages, where the gap between written policy and actual practice left a vulnerable resident without the medications she needed to manage chronic pain, depression, and eye allergies.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Cottages from 2025-08-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
The Cottages in Pella, IA was cited for violations during a health inspection on August 25, 2025.
None of the medications arrived as scheduled.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.