The Cottages: Repeated Falls After Brain Bleeds - IA
The cascade of falls began on June 7, when staff found the resident on her bedroom floor with a moderate amount of bright red blood. They called her daughter and suggested an emergency room visit. The daughter picked up the resident at 9:00 p.m. and called back at 11:15 p.m. to report her mother had been admitted for observation.
Hospital records show the resident sustained a seven-inch gash. A CT scan revealed several areas of intraparenchymal hemorrhages — bleeding directly into the brain tissue typically caused by head trauma.
The falls didn't stop.
On June 28, staff found her on the floor again. She said she was going to the bathroom. No injuries this time. Two days later, on June 30, they discovered her on her back between a recliner and chair. The resident said she hit her head.
July 1 brought a care plan entry directing staff to offer toileting assistance before and after meals. The next day, staff found her on the floor between chairs in her room. She said she had to go to the bathroom.
Three days later, on July 5, the resident was back on the floor. Her head hurt and was bleeding. She told staff she tried to move a table to reach the bathroom.
Five falls. Four involving attempts to reach the bathroom. One hospitalization for brain bleeding.
Yet when state inspectors arrived in August, they found the care plan contained no documentation of interventions based on root cause analysis to prevent future falls.
Staff A, a registered nurse, told inspectors on August 20 that after a resident fell, "they had to come up with a new intervention add it to the care plan." The Director of Nursing echoed this, saying for each fall, "they came up with an intervention and immediately added it to the care plan."
But the records told a different story.
Staff K, a certified nursing assistant, explained they tried to toilet the resident every two hours, "but even with this, she got up by herself." When inspectors asked what specific interventions the facility had directed her to carry out to prevent falls, Staff K could not name any.
She did mention closing the bathroom door so the resident wouldn't be cued to get up. But she figured out this intervention on her own, not through facility direction.
The Director of Nursing admitted the truth when inspectors pressed further on August 21. She could not find any additional interventions for the resident documented in the care plan. The team had discussed interventions, she said, but "they did not make it on the care plan."
She wasn't sure why this happened.
The pattern revealed a facility where staff talked about fall prevention but failed to follow through. A resident who had suffered traumatic brain bleeding continued falling while attempting the basic human need of reaching a bathroom. Each incident was documented. Each prompted promises of intervention.
None of the promised interventions appeared in the resident's care plan.
The inspection found the facility failed to ensure adequate supervision and assistive devices to prevent accidents for residents who had already demonstrated a clear pattern of falls. Federal regulations require nursing homes to identify residents at risk of accidents and implement interventions to prevent them.
For this resident, the risk was obvious after the first hospitalization. The pattern was clear after the second fall. By the fifth fall, with blood on the floor again, the facility's failure to implement effective interventions had caused actual harm.
The resident's daughter had trusted the facility to keep her mother safe after brain trauma. Instead, she received phone calls about fall after fall, each one potentially catastrophic for someone who had already suffered bleeding in the brain.
Staff knew what needed to be done. They told inspectors they developed interventions after each incident. But knowing and doing proved to be different things entirely at The Cottages, where a vulnerable resident paid the price for the gap between promises and practice.
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 20, 2026 · Our methodology
The Cottages in Pella, IA was cited for violations during a health inspection on August 25, 2025.
The cascade of falls began on June 7, when staff found the resident on her bedroom floor with a moderate amount of bright red blood.
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.