The facility's policy outlines a detailed investigation process that includes documenting resident behavior and environmental conditions at the time of incidents. Investigators are supposed to assess any injuries present and observe both resident and staff behaviors during their review.
But inspectors discovered the nursing home wasn't following through on these requirements.
The policy requires investigations to be completed and reviewed with the Executive Director, Administrator, and Director of Nursing. After this review, staff should determine a plan for further action with input from appropriate personnel.
The process should culminate in completion of an Investigative Data Summary designed to prevent future occurrences. Results of the investigation must be recorded and attached to the report.
Inspectors found gaps in this process during their November visit. The facility received a citation for minimal harm or potential for actual harm affecting few residents.
The violation relates to federal requirements that nursing homes maintain complete records of incident investigations. These records serve as critical documentation for tracking resident safety issues and ensuring appropriate follow-up occurs.
When facilities fail to complete investigation documentation, they lose the ability to identify patterns that could prevent future incidents. The missing paperwork also makes it difficult for regulators to verify that proper safety measures are in place.
The Cottages operates at 1742 Main Street in Pella. The facility must submit a plan of correction detailing how it will ensure complete documentation of all incident investigations going forward.
Federal inspectors completed their review on November 25, 2025, following a complaint that triggered the investigation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Cottages from 2025-11-25 including all violations, facility responses, and corrective action plans.