Inspection Report Summary
The most recent inspection on July 18, 2024, identified multiple deficiencies related to assessments, staff training, physical examinations, primary care orders, incident reporting, and service plan development for memory care residents. Earlier inspections showed similar issues with medication orders, medical examinations, and service plans, while complaint investigations from 2022 and 2023 found no deficiencies. Prior complaint investigations in 2020 substantiated deficiencies in supervision that led to a resident fall and death, as well as medication management problems. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows recurring challenges with documentation, staff training, and care planning, with no clear trend of improvement in the most recent report.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
32% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 7
Jul 18, 2024
Visit Reason
The inspection was conducted to determine compliance with licensing rules for a Residential Care Facility with a special classification for Memory Care.
Findings
The facility was found deficient in multiple areas including failure to complete assessments prior to admission for memory care residents, inadequate staff training on memory care needs, lack of physical examinations prior to admission, failure to maintain current primary care provider orders, incomplete incident reporting, and failure to develop initial and ongoing service plans for residents.
Deficiencies (7)
| Description |
|---|
| Failed to complete an assessment prior to admission to the memory care unit for 2 of 3 residents reviewed. |
| Failed to ensure 3 of 7 employees completed six hours of special training prior to assignment to the memory care unit. |
| Failed to obtain a physical examination prior to admission for 3 of 3 residents reviewed. |
| Failed to obtain primary care provider orders on a quarterly basis for 5 of 7 residents reviewed. |
| Failed to complete incident reports when 1 of 4 tenants reviewed displayed unusual behaviors. |
| Failed to develop an initial service plan within 48 hours of admission for 2 of 3 current residents and 1 discharged resident reviewed. |
| Failed to develop a service plan within 30 days of admission for 3 of 4 current residents and 1 discharged resident reviewed. |
Report Facts
Residents reviewed: 7
Residents admitted since May 2024: 3
Residents reviewed for service plans: 4
Discharged residents reviewed: 1
Hours of special training required: 6
Inspection Report
Plan of Correction
Deficiencies: 3
Nov 21, 2023
Visit Reason
The document is a plan of correction responding to deficiencies cited in a prior inspection related to medication orders, medical examinations, and service plans for residents.
Findings
The report identifies deficiencies in medication orders, medical examinations, and service plans, noting failures in ensuring proper orders, timely medical reviews, and updated service plans for residents. The plan outlines corrective actions including staff training, audits, and re-training of nurses.
Deficiencies (3)
| Description |
|---|
| Orders for medications and treatments shall be correctly and timely ordered by qualified personnel. |
| The person in charge shall immediately notify the physician of any accident, injury or adverse change in the resident's condition that has the potential for requiring physician intervention. |
| Service plans shall be prepared within 30 days of admission and reviewed and updated as needed. |
Report Facts
Completion Date: 11/21/2023
Implementation Date: 10/17/2023
Compliance Date: 02/28/2024
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 22, 2023
Visit Reason
The inspection was conducted as an investigation of complaints and incidents identified by Incident #108990-I, Incident #113636-I, and Complaint #111816-C.
Findings
No deficiencies were cited during the investigation of the incidents and complaint.
Complaint Details
Investigation of Incident #108990-I, Incident #113636-I, and Complaint #111816-C found no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 15, 2022
Visit Reason
Investigation into Complaint #105353-C and Incident #106837-I at Corridor Crossing Place.
Findings
No deficiencies were cited during the investigation.
Complaint Details
Investigation was related to Complaint #105353-C and Incident #106837-I; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 29, 2022
Visit Reason
Investigation into Complaint #101532-C at Corridor Crossing Place.
Findings
No deficiencies were cited during the investigation.
Complaint Details
Investigation into Complaint #101532-C found no deficiencies.
Inspection Report
Annual Inspection
Deficiencies: 0
Jan 5, 2022
Visit Reason
The survey was conducted to determine compliance with licensing rules for a Residential Care Facility with a special classification for Memory Care, including an onsite infection control survey.
Findings
No deficiencies were cited during the survey or the infection control survey.
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 8, 2020
Visit Reason
The inspection was conducted as an investigation of complaints and incidents related to supervision and safety at Corridor Crossing Place, Cedar Rapids, Iowa, specifically investigations 92736-C, 92760-C, and 92740-I.
Findings
The facility failed to provide proper supervision levels for one of three residents reviewed, resulting in a resident fall with serious injuries and subsequent death. The investigation found inadequate documentation and training regarding supervision and wheelchair brake use, with multiple staff interviews confirming inconsistent practices.
Complaint Details
The visit was complaint-related with substantiated findings for Incident #92740-I and Complaints #92760-C and #92736-C, all related to supervision and safety.
Deficiencies (1)
| Description |
|---|
| Failure to provide and document proper supervision levels for residents requiring more than general supervision, leading to a resident fall and injury. |
Report Facts
Incident Report Date: Aug 4, 2020
Resident Death Date: Aug 12, 2020
Incident Investigation Dates: Aug 17, 2020
Inspection Date: Sep 8, 2020
Service Plan Date: Jul 1, 2020
Plan of Correction Compliance Date: Jan 8, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Urbanek | Nurse Manager | Named in plan of correction and interview confirming findings |
| Staff A | Interviewed staff involved in medication administration and resident supervision | |
| Staff B | Interviewed staff involved in resident supervision and fall incident | |
| Staff D | Interviewed staff regarding resident mobility and supervision | |
| Staff E | Interviewed staff regarding resident activities and supervision | |
| Staff F | Interviewed staff regarding wheelchair use and resident supervision | |
| Staff G | Interviewed staff regarding wheelchair brake engagement | |
| Staff H | Interviewed staff regarding wheelchair use and resident safety |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 26, 2020
Visit Reason
The inspection was conducted as a complaint investigation related to medication management and other concerns at Corridor Crossing Place.
Findings
The investigation substantiated a deficiency in medication management where staff failed to properly observe residents swallowing their medications, leaving pills unattended, and not following physician orders for self-administration. Other complaint areas such as supervision and evaluation/service plan were not substantiated.
Complaint Details
Complaint investigation #90635-C found medication management deficiency substantiated; supervision and evaluation/service plan complaints were not substantiated.
Deficiencies (1)
| Description |
|---|
| Failure to ensure drug administration was properly carried out for 3 of 9 residents reviewed, including not observing residents swallow medications and leaving pills unattended. |
Report Facts
Residents reviewed: 9
Residents with medication administration issues: 3
Dates of physician orders: Jul 10, 2020
Dates of physician orders: Jul 15, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Urbanek | Nurse Manager | Named in plan of correction and confirmation of medication administration procedures |
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