Inspection Reports for
Grand Living at Indian Creek
325 Collins Road SE, Cedar Rapids, IA, 52403
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Inspection Report — Nov 19, 2025
Renewal
Date: Nov 19, 2025
Visit Reason
Scheduled recertification visit to determine compliance with certification of an Assisted Living Program. The visit also investigated Incident #130397-I, Incident #130641-I, Incident #130642-I, Incident #130639-I, and Complaint #130302-C.
Complaint Details
Incident #130397-I, Incident #130641-I, Incident #130642-I, Incident #130639-I, and Complaint #130302-C were investigated with no regulatory insufficiencies cited.
Findings
No regulatory insufficiencies were cited during the investigation of the listed incidents and complaint.
Inspection Report — Aug 27, 2025
Complaint Investigation
Date: Aug 27, 2025
Visit Reason
The inspection was conducted related to the investigation of complaints #127819-C and #128010-C concerning regulatory insufficiencies at the assisted living program Grand Living at Indian Creek.
Complaint Details
The visit was complaint-related, investigating complaints #127819-C and #128010-C. The complaint involved issues with involuntary transfer notification, documentation of nurse's notes, and service plan updates. The Executive Director confirmed the long-term care ombudsman was contacted by phone a week after the transfer notice was given for Tenant C1. The complaints were substantiated by the findings.
Findings
The program failed to immediately notify the long-term care ombudsman of an involuntary transfer, failed to document nurse's notes by exception for discharged tenants, and failed to update service plans to reflect tenants' service needs and changes. These deficiencies pertained to two discharged tenants (Tenant C1 and Tenant C2) and involved issues such as non-compliance with smoking policies, safety concerns, and incomplete documentation.
Violations (3)
Failed to immediately provide notification of involuntary transfer to the long-term care ombudsman for Tenant C1.
Failed to document nurse's notes by exception for discharged tenants Tenant C1 and Tenant C2.
Failed to update service plans as needed and ensure service plans reflected the service needs of Tenant C1 and Tenant C2.
Report Facts
30-day notice dates: 2
Discharge dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Confirmed LTC Ombudsman was contacted regarding Tenant C1's involuntary transfer and 30-day notice | |
| Director of Health and Wellness | Provided timeline of Tenant C1's hospitalizations and confirmed nurse's notes and service plans were provided |
Inspection Report — Feb 11, 2025
Renewal
Date: Feb 11, 2025
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program.
Findings
The program failed to administer medications and treatments according to physician orders for 3 of 5 tenants reviewed, failed to provide appropriate documentation for significant changes in tenant conditions, failed to develop and update service plans for tenants, and failed to complete required nurse reviews for tenants receiving medication management services.
Violations (6)
Failure to administer medications and treatments in accordance with physician's orders for 3 of 5 tenants reviewed.
Failure to provide appropriate documentation regarding significant change of condition for 1 of 5 tenants reviewed.
Failure to develop service plans for tenants identified as Independent Living but residing in Assisted Living units and failure to update service plans for 1 of 5 tenants reviewed.
Failure to ensure 30 day service plan updates were completed for 2 of 2 tenants admitted in the past 6 months who received personal care services.
Failure to include sufficient information in service plans for 2 of 3 tenants reviewed who utilized outside services.
Failure to complete nurse reviews for 2 of 2 tenants who received medication management services and resided at the program for over three months.
Report Facts
Number of tenants without cognitive impairment: 41
Number of tenants with cognitive impairment: 0
Tenants reviewed for medication administration: 5
Tenants reviewed for documentation of significant change: 5
Tenants reviewed for service plans: 5
Tenants reviewed for 30 day service plan updates: 2
Tenants reviewed for sufficient service plan information: 3
Tenants reviewed for nurse reviews: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joan Randall | Executive Director | Signed the initial comments section of the report. |
| Director of Health and Wellness | Director of Health and Wellness | Provided multiple confirmations and interviews regarding medication administration, documentation, service plans, and nurse reviews. |
| Assistant Director of Health and Wellness | Assistant Director of Health and Wellness | Confirmed correct medication dosages and participated in education and audits related to service plans and medication management. |
| Vice President of Operations | Vice President of Operations | Confirmed tenants identified as Independent Living did not have service plans in place. |
Inspection Report — May 3, 2023
Renewal
Date: May 3, 2023
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for an Assisted Living Program and to investigate Complaint #112524-C.
Complaint Details
The visit included an investigation into Complaint #112524-C.
Findings
The program failed to develop individualized service plans addressing the wants and needs of 3 of 5 tenants reviewed, including issues with care resistance, behavioral concerns, and incomplete fall risk management. The deficiencies were confirmed by facility leadership.
Violations (5)
Failure to develop individualized service plans addressing tenant needs and preferences for assistance for Tenants #1, #2, #3, and #4.
Tenant #1's service plan did not reflect resistance to intimate cares and grooming needs.
Tenant #2's service plan did not address sexually inappropriate behaviors reported by staff.
Tenant #4's service plan was changed to add assistance with dressing, which was not properly documented as a non-discretionary change.
Tenant #5's service plan did not address all fall needs despite 14 falls reported between 2/28/23 and 4/24/23.
Report Facts
Falls: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health and Wellness | Confirmed findings on 5/3/23 at 4:15 PM | |
| Assistant Director of Health and Wellness | Confirmed findings on 5/3/23 at 4:15 PM | |
| RN | Confirmed findings on 5/3/23 at 4:15 PM |
Inspection Report — Jun 7, 2021
Renewal
Date: Jun 7, 2021
Visit Reason
The inspection was a recertification visit conducted to determine compliance with certification for an Assisted Living Program.
Findings
The inspection identified multiple regulatory insufficiencies including failure to ensure staff completed approved medication aide or manager courses before administering medications, failure to document nurse delegation training within required timeframes, failure to complete cognitive evaluations with changes in tenant condition, failure to update service plans based on evaluations and tenant needs, and failure to complete nurse reviews at least every 90 days for tenants receiving personal or health-related care.
Violations (6)
Failed to ensure staff completed an approved medication aide or manager course and passed the examination prior to administering medications.
Failed to document nurse delegation training by the registered nurse within 60 days of hire for staff employed prior to the RN's hire date.
Failed to complete nurse delegated training by the registered nurse within 30 days of employment for staff hired after the delegating nurse was employed.
Failed to complete cognitive evaluations with a change in tenant condition for 2 of 4 tenants reviewed.
Failed to update service plans as needed, failed to complete service plans based on evaluations, and failed to ensure service plans reflected identified service needs for 7 tenants reviewed.
Failed to complete nurse reviews at least every 90 days for 5 tenants receiving personal or health-related care.
Report Facts
Staff reviewed for medication training: 5
Tenants reviewed for service plans and evaluations: 7
Tenants reviewed for nurse reviews: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in medication administration training deficiency and nurse delegation training | |
| Staff B | Named in nurse delegation training deficiency | |
| Staff C | Named in medication administration training deficiency and nurse delegation training | |
| Staff D | Named in medication administration training deficiency and nurse delegation training | |
| Staff E | Named in medication administration training deficiency and nurse delegation training | |
| Staff F | Named in nurse delegation training deficiency | |
| Staff G | Licensed Practical Nurse | Provided training and completed orientation checklists for staff |
| Director of Health and Wellness | Registered Nurse | Interviewed and confirmed training and evaluations; named in deficiencies related to nurse delegation and evaluations |
| Executive Director | Interviewed regarding tenant activities and service plans |
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