Inspection Reports for
The Keystones of Cedar Rapids
6325 Rockwell Dr NE, Cedar Rapids, IA, 52402
Back to Facility Profile5 Reports
Inspection Report — Aug 6, 2024
Recertification
Date: Aug 6, 2024
Visit Reason
The recertification visit was conducted to determine compliance with certification of a Dedicated Dementia Specific Assisted Living Program.
Findings
The program failed to complete evaluations as needed with significant change for tenants, specifically related to wound care and service plans. Several tenants' service plans did not reflect current treatments or risks, and evaluations were not updated as required.
Violations (2)
Program failed to complete evaluations as needed with significant change for Tenant #2 related to wound care.
Service plans were not updated to reflect current treatments, risks, or interventions for multiple tenants (#1, #2, #3, #4).
Report Facts
Number of tenants without cognitive impairment: 2
Number of tenants with cognitive impairment: 10
Wound measurement: 2.3
Wound measurement: 3.3
Wound measurement: 0.02
Wound surface area: 7.59
Medication dosage: 100
Medication duration: 10
Therapy frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health and Wellness | Interviewed on 8/6/24 regarding tenant evaluations and service plans |
Inspection Report — Apr 20, 2023
Complaint Investigation
Date: Apr 20, 2023
Visit Reason
The inspection was conducted following investigation of Incident #112364-I involving an elopement of Tenant #1 at Keystone Cedars Memory Care.
Complaint Details
The complaint investigation was triggered by Incident #112364-I involving Tenant #1's elopement on 4/16/23. The investigation found the program did not respond properly to door alarms, delayed notification to leadership, and inadequate safety checks. The complaint was substantiated based on these findings.
Findings
The program failed to follow its policies and procedures related to missing persons and door alarms, resulting in an elopement incident. Additionally, the service plan for Tenant #1 did not reflect specific safety needs or updated interventions after multiple elopements. Door alarms were malfunctioning or not responded to timely, and staff failed to notify leadership promptly.
Violations (2)
Failure to follow program policies and procedures related to missing persons and elopement prevention.
Failure to develop and update a service plan that identifies specific needs and safety interventions for a tenant with a history of elopement.
Report Facts
Elopement incidents: 2
Safety check frequency: 2
Door alarm reset delay: 40
Temperature: 38
Wind speed: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Responded to door alarm, found Tenant #1 outside, unable to silence door alarm, involved in incident | |
| Staff B | Assisted in search for Tenant #1, notified Director of Health and Wellness, involved in incident | |
| Director of Health and Wellness | Director of Health and Wellness | Called to incident, assessed Tenant #1, provided education and training, involved in policy updates |
| Executive Director | Executive Director | Notified of elopement, reviewed incident and video footage, involved in corrective actions and policy updates |
| Staff C | Observed staff activity during incident, reported confusion due to pager issues | |
| Staff D | Provided shift report and observations related to Tenant #1 |
Inspection Report — Apr 19, 2023
Enforcement
Date: Apr 19, 2023
Visit Reason
Investigation #112364-I was conducted due to an elopement incident involving Tenant #1 at Keystone Cedars Memory Care. The citation addresses failure to follow the program's policies and procedures related to tenant safety and door alarm response.
Findings
The facility failed to follow its policies and procedures, resulting in Tenant #1 eloping twice, including on 4/16/23. Staff did not respond properly to door alarms, failed to communicate tenant status promptly, and delayed notifying the Director of Health and Wellness (DHW). Tenant #1 was found outside without injuries but without his walker.
Violations (1)
IAC 481-67.2(3) The program failed to follow its policies and procedures. Staff did not respond promptly or properly to door alarms, failed to communicate tenant status, and delayed notifying the DHW, resulting in Tenant #1 eloping twice.
Report Facts
Fine amount: 5000
Inspection Report — Feb 21, 2022
Complaint Investigation
Date: Feb 21, 2022
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program and to investigate Complaint #102204-C and Incident #102301-I.
Complaint Details
Complaint #102204-C and Incident #102301-I were investigated related to incidents involving Tenant #1 elopements and staff conduct.
Findings
The program failed to follow its policies and procedures related to incident reports and responding to door alarms, failed to treat a tenant with dignity and respect, failed to provide services according to training, failed to complete evaluations and nurse reviews as needed, failed to develop and update service plans based on evaluations, and failed to ensure staff completed required dementia-specific training within 30 days of hire.
Violations (8)
Failed to follow policy and procedures related to incident reports and responding to door alarms, including multiple elopements of Tenant #1 without proper documentation or staff response.
Failed to ensure Tenant #1 was treated with consideration, respect, and dignity, including verbal abuse and inappropriate physical actions by staff.
Failed to provide services in accordance with training, including improper medication administration to Tenant #3.
Failed to complete evaluations as needed with significant change for tenants with wounds and catheters (Tenants #3 and #4).
Failed to discharge Tenant #1 who exceeded the level of care due to chronic elopement and aggressive behaviors.
Failed to develop and update service plans based on evaluations and tenant needs for all five tenants reviewed.
Failed to complete nurse reviews as needed when there was a change in tenants' health status for tenants with wounds (Tenants #3 and #5).
Failed to have staff complete eight hours of dementia-specific education within 30 days of employment for two staff members.
Report Facts
Number of tenants without cognitive disorder: 0
Medication dosage: 10
Medication dosage: 40
Weight loss: 11.8
Dementia training hours: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Named in findings related to verbal abuse and physical mistreatment of Tenant #1 | |
| Staff E | Reported verbal abuse and physical mistreatment of Tenant #1 by Staff G | |
| Staff D | Administered medication improperly to Tenant #3 | |
| Nurse #2 | On-call nurse | Involved in investigation of staff concerns regarding Tenant #1 |
| Executive Director | Provided interviews and information about incident reports, staff training, and tenant care |
Inspection Report — Feb 10, 2022
Enforcement
Date: Feb 10, 2022
Visit Reason
This citation was issued following a recertification visit and investigations of incidents identified by Type of Action codes 102204-C and 102321-I. The facility was cited for failure to follow its policies and procedures related to incident reports and responding to door alarms, and for verbal abuse of a tenant.
Complaint Details
Type of Action: 102204-C, 102321-I, recert
Findings
The facility failed to follow its policies and procedures for incident reporting and door alarm responses, resulting in multiple incidents where Tenant #1 left the memory care unit without proper staff response or documentation. Staff also verbally abused Tenant #1 and failed to complete required incident reports.
Violations (2)
67.2(3) The program failed to follow its policies and procedures related to incident reports and responding to door alarms. Tenant #1 left the memory care unit multiple times without proper staff response, notification, or documentation of vital signs and witness statements.
Staff verbally abused Tenant #1 by yelling at her, holding the bathroom door shut to prevent her from leaving, and putting an ice cube down her back. No incident report was completed for these incidents.
Report Facts
Fine amount: 2500
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