The Cottages
Inspection Findings
F-Tag F0605
Federal health inspectors cited The Cottages in Pella, IA for a deficiency under regulatory tag F-F0605 during a standard health inspection conducted on 2025-08-25.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
The facility was found deficient in the following area: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of The Cottages.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-25.
F-Tag F0656
Federal health inspectors cited The Cottages in Pella, IA for a deficiency under regulatory tag F-F0656 during a standard health inspection conducted on 2025-08-25.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of The Cottages.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-25.
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
moderate amount of bright red blood. Staff called the resident's daughter and suggested an ER visit. The daughter picked up the resident at approximately 9:00 p.m. and called back at 11:15 p.m. to say the resident was admitted for observation for four brain bleeds. A hospital History and Physical Report, dated 6/7/25, stated the resident presented to the ER due to a fall. The resident sustained a 7 inch gash and the computerized tomography(CT) scan(a scan which used a series of X-ray images taken from different angles to create detailed cross-sectional images of the inside of the body, helping doctors diagnose conditions, plan treatments, and monitor disease progression) showed several areas of intraparenchymal hemorrhages(bleeding directly into the brain's tissue [parenchyma] and often caused by head trauma). A 6/28/25 4:48 p.m. Unwitnessed Fall report stated the resident laid on the floor and stated she was going to
the bathroom. She had no injuries. A 6/30/25 Unwitnessed Fall report stated the resident was found on the floor on her back between the recliner and the other side of the chair. The resident stated she hit her head.
A 7/1/25 Care Plan entry directed staff to offer the resident toileting assistance before and after meals. A 7/2/25 Unwitnessed Fall report stated staff found the resident on the floor between her chairs in her room.
The resident said she had to go to the bathroom. A 7/5/25 Unwitnessed Fall report stated the resident was
on the floor and her head hurt and was bleeding. The resident stated she tried to move the table to go to
the bathroom. The Care Plan lacked documentation of further interventions related to the above falls using root cause analysis to create preventative measures.On 8/20/25 at 1:28 p.m., Staff A Registered Nurse (RN) stated after a resident fell they had to come up with a new intervention add it to the care plan. On 8/20/25 at 3:27 p.m., the Director of Nursing (DON) stated for each fall, they came up with an intervention and immediately added it to the care plan. She stated with regard to Resident #20, she would do some research to find out which interventions were implemented. On 8/21/25 at 11:22 a.m., Staff K CNA stated Resident #20 got up on her own and fell. She stated they tried to toilet her every two hours but even with this, she got up by herself. When queried regarding any interventions that the facility directed her to carry out in order to prevent the resident from falling, Staff K could not name any. Staff K did say that she closed
the bathroom door so the resident was not cued to get up but stated she figured this intervention out on her own. On 8/21/25 at 1:42 p.m., the DON stated she did not find any additional interventions for the resident
on the care plan. She stated the team came up with interventions but they did not make it on the care plan.
She stated she was not sure why this happened.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/25/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Cottages
1742 Main Street Pella, IA 50219
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0695
Federal health inspectors cited The Cottages in Pella, IA for a deficiency under regulatory tag F-F0695 during a standard health inspection conducted on 2025-08-25.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of The Cottages.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-25.
F-Tag F0755
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, and staff interview, the facility failed to ensure the availability of routine medications for 1 of 4 newly admitted residents(Resident #99). The facility reported a census of 95 residents. Findings:The Minimum Data Set(MDS) assessment tool, dated 4/27/25, listed diagnoses for Resident #99 which included rheumatoid arthritis, weakness, and depression and listed the resident's Brief
Interview for Mental Status(BIMS) score as 14 out of 15, indicating intact cognition. The MDS documented that the resident was admitted on [DATE REDACTED] from a hospital.The undated facility policy Pharmacy-Initiated Order Workflow stated the nurse received a signed order from the prescriber and faxed it to the pharmacy.
The pharmacy then processed the medication and delivered it to the facility. The procedure did not address what staff should do if a medication did not arrive from the pharmacy. A 4/25/2025 10:30 a.m. Clinical admission entry stated the resident admitted to the facility. The April Medication Administration Record(MAR) listed the following 4/25/25 orders: a. Alrex suspension 0.2%(an eye drop used to treat allergies of the eye), instill one drop in both eyes. The following doses lacked a checkmark to indicate staff administered the medication and had 9 for the entry which referred to the resident's Progress Notes: 5/25/25 4:00 p.m. and 8:00 p.m. doses, 5/26/25 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. doses, 5/27/25 12:00 p.m. and 4:00 p.m. doses.B. Pregabalin (a medication used to treat nerve pain) 100 milligrams(mg) three times per day. The following doses lacked a checkmark to indicate staff administered
the medication and had 9 for the entry which referred to the resident's progress notes: 5/25/25 4:00 p.m. dose, 5/26/25 8:00 p.m. dose, 5/27/25 6:00 a.m. 12:00 p.m., and 8:00 p.m. dosesC. Duloxetine (an antidepressant) 30mgs 1 capsule twice daily. The 5/25/25 4:00 p.m. entry lacked staff initials to indicate staff administered the medication and had a 9 for the entry which referred to the progress notes. Progress Notes entered on the following dates and times stated that the resident's Alrex eye drop was not available: 4/25/25 5:53 p.m., 4/25/25 9:07 p.m., 4/26/25 9:33 a.m., 4/26/25 11:12 a.m., 4/26/25 6:02 p.m., 4/26/25 8:41 p.m., 4/27/25 10:45 a.m. Progress Notes entered on the following dates and times stated that the resident's Pregabalin was not available: 4/25/25 2:18 p.m., 4/26/25 9:11 a.m., 4/27/25 11:05 a.m.A 4/25/25 2:17 p.m Progress Note stated the resident's Duloxetine was not available. The Progress Notes did not contain documentation the facility staff contacted the pharmacy to follow up on the missing medications.A 4/27/25 7:00 p.m., Nurses Note stated the resident left the facility with her spouse Against Medical Advice(AMA). On 8/20/25 at 1:28 p.m., Staff A Registered Nurse(RN) stated when Resident #99 admitted
they had trouble getting her Pregabalin. She stated she received education that she should call the provider to obtain the medication. She stated it wasn't appropriate to just wait for the pharmacy. On 8/20/25 at 3:27 p.m., the Director of Nursing(DON) stated if a medication did not arrive from the pharmacy, staff could call for a stat delivery. If the resident didn't come with an order, staff should reach out to the provider and obtain
an order for the medication or an order to hold.
Event ID:
Facility ID:
If continuation sheet
F-Tag F0759
Federal health inspectors cited The Cottages in Pella, IA for a deficiency under regulatory tag F-F0759 during a standard health inspection conducted on 2025-08-25.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure medication error rates are not 5 percent or greater.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of The Cottages.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-25.
F-Tag F0760
Federal health inspectors cited The Cottages in Pella, IA for a deficiency under regulatory tag F-F0760 during a standard health inspection conducted on 2025-08-25.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure that residents are free from significant medication errors.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of The Cottages.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-25.
F-Tag F0880
Federal health inspectors cited The Cottages in Pella, IA for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-25.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of The Cottages.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-25.
F-Tag F0883
Federal health inspectors cited The Cottages in Pella, IA for a deficiency under regulatory tag F-F0883 during a standard health inspection conducted on 2025-08-25.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Develop and implement policies and procedures for flu and pneumonia vaccinations.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of The Cottages.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-25.
The Cottages in Pella, IA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Pella, IA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from The Cottages or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.