Inspection Reports for
Prairie Hills at Cedar Rapids

The visit was complaint-related involving allegations of abuse and failure to follow policies and procedures. Tenant C1 alleged staff roughness and bruising during transfer, which was not properly documented or investigated.

The Program failed to follow established policies and procedures related to medication administration, incident reporting, abuse policy, and documentation of tasks. Deficiencies were found in wound care documentation, incident reporting, nurse delegation, tenant evaluations, service plans, nurse reviews, and food temperature control.

The investigation was triggered by allegations of verbal abuse and neglect by Staff A towards Tenant #1, Tenant C1, and Tenant C2. The complaint was substantiated based on staff statements, tenant interviews, video evidence, and internal investigation. Staff A was suspended pending investigation and subsequently terminated for violating the Dependent Adult Abuse Policy.

The program failed to have a policy consistent with Iowa Code chapter 235E requiring separation of victim and alleged abuser, potentially affecting all 43 tenants. Additionally, Staff A was found to have verbally abused and neglected care duties for three tenants, including refusal to assist with toileting and transfers, yelling at tenants, and instructing tenants not to call for help, leading to Staff A's suspension and termination.

Complaint #115034-C was investigated and found to have no regulatory insufficiencies.

No regulatory insufficiencies were cited during the investigation.

The visit was complaint-related, investigating Complaints #105632-C and #109460-C. The complaints involved medication errors, policy violations, and possible unauthorized drug activity by staff.

The Program failed to follow multiple policies and procedures including insulin administration, medication administration, incident report completion, and the Drug and Alcohol policy. Medication errors were identified for multiple tenants, including administration of insulin despite blood glucose parameters, administration of discontinued medications, and administration of medications from the wrong medication planner. Evaluations and service plans were not completed or updated as required. Nurse's notes were not documented by exception for a hospitalized tenant. Food service staff did not receive timely orientation on sanitation and safe food handling.

The program failed to administer medications as prescribed for two current tenants and one discharged tenant, resulting in medication errors including double dosing, administering discontinued medications, and giving wrong medications from incorrect planners.

Complaint #98357-C was investigated and found to have no regulatory insufficiencies.

No regulatory insufficiencies were cited during the investigation of the complaint.

Investigation of Incident #98189-I regarding a tenant's suicide attempt. The incident was substantiated as the program did not report the event timely to the Department.

The program failed to notify the Department within 24 hours or the next business day of the tenant's suicide attempt, despite evidence from interviews and record reviews. The tenant took approximately 97 tablets of medication and was admitted to the hospital for monitoring and psychiatric evaluation.

Complaint #93272-C was investigated during the recertification visit and on-site infection control survey. The complaint involved incidents with two tenants, including falls and inadequate care. The complaint was substantiated as evidenced by the cited deficiencies.

The facility was found to have regulatory insufficiencies related to program policies and procedures, tenant rights, and staffing. Specifically, failures were noted in following incident report policies, providing adequate care and treatment to two tenants, and ensuring nurse delegation training compliance among staff.

Complaint 93272

The program failed to provide adequate and appropriate care to two former tenants. Tenant #1 was found unresponsive and died after staff failed to properly respond to low oxygen saturation and symptoms. Tenant #2 suffered a fall, was moved despite severe pain, sustained a hip fracture, and later died.

Complaint #91786-C was investigated from July 21, 2020 through October 7, 2020. The complaint involved issues with occupancy agreements, tenant rights, care and services, tenant evaluations, and service plans.

No regulatory insufficiencies were cited during the infection control survey; however, deficiencies were found related to failure to provide written occupancy agreements, inadequate tenant rights protections, failure to provide adequate and appropriate care and services, incomplete tenant evaluations, and failure to update service plans as needed.