Inspection Reports for Cottage Grove Place
2115 1st Ave SE, Cedar Rapids, IA, 524026358
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 17, 2025, identified deficiencies related to head injury policies, medication administration, and updating tenant evaluations and service plans. Earlier inspections showed a pattern of issues with service plans, medication administration, documentation, and staff training, with some complaints substantiated regarding tenant evaluations and service plans. Complaint investigations were mostly unsubstantiated except for one in 2020 involving tenant evaluations and service plans, and another in 2008 related to medication administration and health assessments. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows recurring themes around service plan management and medication practices, with no clear trend of improvement or worsening over time.
Deficiencies (last 15 years)
Deficiencies (over 15 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
70% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
37 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 37
Deficiencies: 4
Sep 17, 2025
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification of an Assisted Living Program.
Findings
The program failed to follow policies and procedures related to head injuries and medication administration for multiple tenants. Additionally, evaluations and service plans were not completed or updated as needed following significant changes for some tenants.
Deficiencies (4)
| Description |
|---|
| Failed to follow policy and procedure related to head injuries and medication administration for 2 of 4 tenants reviewed. |
| Failed to administer medications and treatments as prescribed by the tenant's physician for 3 of 4 tenants reviewed. |
| Failed to complete evaluations as needed with significant change for 2 of 4 tenants reviewed. |
| Failed to update service plans as needed and failed to have service plans reflect the service needs of tenants for 2 of 4 tenants reviewed. |
Report Facts
Total census: 37
Falls recorded for Tenant #1: 5
Falls recorded for Tenant #3: 8
Medication not administered: 20
TED hose not completed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assisted Living Manager | Confirmed provision of nurse's notes, faxes, MARs, evaluations, and service plans during interviews. | |
| Assisted Living Nurse Manager | Confirmed all service plans were provided for tenants reviewed. |
Inspection Report
Recertification
Census: 35
Deficiencies: 5
May 3, 2023
Visit Reason
The inspection was conducted as a recertification visit and complaint investigations (#107526-C and #111379-C) to determine compliance with certification rules for an Assisted Living Program.
Findings
The inspection identified regulatory deficiencies including failure to obtain signed occupancy agreements prior to tenant occupancy, incomplete nurse's notes documentation by exception, inadequate service plans not reflecting tenant needs, lack of proper food safety training for staff, and a malfunctioning 24-hour personal emergency response system with delayed or missed pendant alerts.
Complaint Details
No regulatory insufficiencies were identified related to Complaint #107526-C. Deficiencies were cited related to Complaint #111379-C.
Deficiencies (5)
| Description |
|---|
| Failed to obtain signed occupancy agreement prior to tenant occupancy for 2 of 4 tenants reviewed. |
| Failed to document nurse's notes by exception for 2 of 4 tenants reviewed. |
| Failed to develop service plans reflecting specific service needs of tenants for 4 of 4 tenants reviewed. |
| Failed to provide staff with orientation on safe food handling prior to handling food and annual in-service training on food safety for 4 of 5 staff reviewed. |
| Failed to have a functioning 24-hour personal emergency response system; pendant calls had delayed responses, unanswered alerts, and system issues affecting tenant safety. |
Report Facts
Total tenants without cognitive impairment: 35
Total tenants with cognitive impairment: 0
Total census: 35
Pendant call response times: 15
Pendant call response times: 4
Pendant calls unanswered: 50
Inspection Report
Renewal
Census: 11
Deficiencies: 2
Mar 15, 2021
Visit Reason
The visit was a recertification inspection to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the onsite infection control survey. However, regulatory insufficiencies were cited during the recertification visit related to background checks and service plans for tenants.
Deficiencies (2)
| Description |
|---|
| Program failed to complete valid background checks prior to employment for 2 of 6 staff reviewed. |
| Program failed to update tenants' service plans as needed and failed to develop service plans to reflect identified service needs for 2 of 2 tenants reviewed. |
Report Facts
Number of tenants without cognitive disorder: 9
Number of tenants with cognitive disorder: 2
Total population at time of on-site: 11
Staff reviewed for background checks: 6
Tenants reviewed for service plans: 2
Inspection Report
Complaint Investigation
Census: 13
Deficiencies: 3
Oct 15, 2020
Visit Reason
The investigation of Complaint #93973-C was completed to evaluate compliance with regulatory requirements related to tenant evaluations and service plans at Cottage Grove Place.
Findings
The program failed to complete evaluations and update service plans as needed with significant changes for tenants. Specific deficiencies included incomplete evaluations within 30 days of occupancy, failure to document nurses' notes by exception, and failure to update service plans timely reflecting significant changes in tenant behaviors.
Complaint Details
Investigation #93973-C was completed and resulted in regulatory insufficiencies related to tenant evaluations and service plans. The complaint was substantiated based on interviews and record reviews indicating failures in evaluation and documentation.
Deficiencies (3)
| Description |
|---|
| Program failed to complete evaluations as needed with significant change for tenants. |
| Program failed to document nurses' notes by exception for tenants. |
| Program failed to update service plans within 30 days and as needed with significant change. |
Report Facts
Number of tenants without cognitive disorder: 11
Number of tenants with cognitive disorder: 2
Total population of program at time of on-site: 13
Date survey completed: Oct 15, 2020
Inspection Report
Routine
Census: 11
Deficiencies: 0
Jul 30, 2020
Visit Reason
The inspection was conducted as an onsite infection control survey of the Assisted Living Program.
Findings
There were no regulatory insufficiencies cited during the onsite infection control survey completed on 7/30/2020.
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 0
Oct 28, 2019
Visit Reason
Investigation into Complaint #86380-C at the assisted living program.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Complaint Details
Investigation into Complaint #86380-C found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 9
Number of tenants with cognitive disorder: 5
Total census: 14
Inspection Report
Renewal
Census: 19
Deficiencies: 0
Mar 25, 2019
Visit Reason
Recertification conducted to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification inspection of the Assisted Living Program.
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 0
Jan 10, 2019
Visit Reason
The inspection was conducted as an investigation of Complaint #80261-C at the Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Complaint Details
Investigation of Complaint #80261-C found no regulatory insufficiencies.
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 0
Mar 8, 2018
Visit Reason
Investigation of Complaint #74302-C at the assisted living facility.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Complaint Details
Investigation of Complaint #74302-C found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 15
Number of tenants with cognitive disorder: 4
Total census: 19
Inspection Report
Renewal
Census: 19
Deficiencies: 2
Mar 23, 2017
Visit Reason
The recertification visit was conducted to determine compliance with certification for an Assisted Living Program (ALP).
Findings
The program failed to ensure service plans were signed by tenants or their legal representatives when significant changes triggered updates, and failed to develop service plans indicating tenants' identified needs for 3 of 4 tenant files reviewed.
Deficiencies (2)
| Description |
|---|
| Service plans were not signed and dated by tenants or their legal representatives after significant changes for 3 of 4 tenant files. |
| Service plans failed to indicate tenants' identified needs and preferences for assistance for 3 of 4 tenant files reviewed. |
Report Facts
Number of tenants without cognitive disorder: 15
Number of tenants with cognitive disorder: 4
Total population of program at time of on-site: 19
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 0
Mar 8, 2016
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding an allegation that the program did not release copies of documents to family when requested.
Findings
The allegation was found to be not substantiated. Interviews with staff indicated that documents for tenants with cognitive impairment are released to family if legal documents are presented, and copies of admission documents were provided when requested. No regulatory insufficiencies were identified.
Complaint Details
Allegation: Admission/Discharge—It was alleged a Program did not release copies of documents to family when requested. Findings: Not substantiated.
Report Facts
Number of tenants without cognitive disorder: 17
Number of tenants with cognitive disorder: 1
Total Population of Program at time of on-site: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Signed report and contact person for questions |
Inspection Report
Renewal
Census: 19
Deficiencies: 0
Mar 18, 2015
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation to determine compliance with certification for an Assisted Living Program at Cottage Grove Place.
Findings
No regulatory insufficiencies were found during the evaluation. The recertification documents and State Fire Marshal's inspection report were accepted.
Report Facts
Number of tenants without cognitive disorder: 15
Number of tenants with cognitive disorder: 4
Total census of Assisted Living Program: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Signed the Final Recertification Monitoring Evaluation Report letter |
Inspection Report
Monitoring
Census: 18
Deficiencies: 0
Dec 13, 2012
Visit Reason
The visit was a final recertification monitoring evaluation conducted to review recertification documents and perform an onsite monitoring evaluation of the Assisted Living Program at Cottage Grove Place.
Findings
No regulatory insufficiencies were found during the evaluation. Tenant satisfaction was positive, with services meeting expectations and no deficiencies noted during the onsite monitoring.
Report Facts
Number of tenants without cognitive disorder: 13
Number of tenants with cognitive disorder: 5
Total Population of Program at time of on-site: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jenna Gardner | Health Care Administrator | Named as Health Care Administrator of Cottage Grove Place |
| Margaret Kaltefleiter | RN MS | Monitor conducting the evaluation |
| Rose Boccella | Program Coordinator | Author of the cover letter for the Final Recertification Monitoring Evaluation Report |
Inspection Report
Monitoring
Census: 15
Deficiencies: 0
Apr 26, 2011
Visit Reason
The visit was a final recertification monitoring evaluation conducted to review recertification documents and assess compliance with Iowa Administrative Code chapters 481-67 and 481-69 for the Assisted Living Program at Cottage Grove Place.
Findings
No regulatory insufficiencies were found during the evaluation. The program did not receive any regulatory insufficiencies during this certification period, and the onsite monitoring evaluation confirmed compliance.
Report Facts
Tenants with dementia: 5
Tenants without cognitive disorder: 10
Total Population: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | MA | Monitor for the evaluation |
| Margaret Kaltefleiter | RN MS | Monitor for the evaluation |
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 0
Mar 31, 2010
Visit Reason
The visit was conducted as a final incident investigation following a report of medication tampering and loss at Cottage Grove Place, an assisted living facility in Cedar Rapids, IA.
Findings
The investigation found no regulatory insufficiencies. The program reported medication loss due to tampering but was unable to identify a perpetrator. The program did not complete random drug testing at the time of the loss but reported the incident appropriately.
Complaint Details
The complaint involved tampering with a tenant's medication bubble pack containing Lortab, with evidence of missing tablets. The program had released two bubble packs to police for fingerprinting, but no perpetrator was identified. Approximately 23 staff had access to the narcotic box during the relevant period. No regulatory insufficiencies were substantiated.
Report Facts
Current number of tenants without cognitive disorder: 15
Current number of tenants with cognitive disorder: 3
Total Population: 18
Staff with access to narcotic box: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor conducting the incident investigation |
Inspection Report
Monitoring
Census: 14
Deficiencies: 0
Jan 13, 2009
Visit Reason
An on-site monitoring evaluation was conducted at Cottage Grove Place as part of the recertification monitoring evaluation process.
Findings
No regulatory insufficiencies were found during this on-site recertification monitoring evaluation. Tenants expressed satisfaction with staffing, food, activities, and safety measures.
Report Facts
Current number of tenants without cognitive disorder: 12
Current number of tenants with cognitive disorder: 2
Total Population: 14
Community meeting attendance: 9
Date of monitoring visit: Jan 13, 2009
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 1
Apr 29, 2008
Visit Reason
A complaint investigation on-site visit was conducted at Cottage Grove Place on April 29, 2008, to investigate concerns related to tenant medications and regulatory compliance.
Findings
The program did not consistently assess and document the health status of each tenant, make recommendations and referrals as appropriate, and monitor progress on previous recommendations. The tenant returned to the program with orders to continue the same medications as at the Nursing Facility, resolving the medication issue.
Complaint Details
Complaint investigation #17310 was substantiated regarding regulatory insufficiency in medication administration and tenant health assessment.
Deficiencies (1)
| Description |
|---|
| The program did not consistently assess and document the health status of each tenant, make recommendations and referrals as appropriate, and monitor progress on previous recommendations. |
Report Facts
Current number of tenants without cognitive disorder: 14
Current number of tenants with cognitive disorder: 0
Total Population: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | SW MA | Monitor for the complaint investigation |
Inspection Report
Monitoring
Census: 15
Deficiencies: 2
Jan 6, 2005
Visit Reason
The on-site monitoring evaluation was conducted as a re-certification monitoring visit to assess compliance with assisted living program regulations at Cottage Grove Place.
Findings
The program had individualized service plans for tenants but did not address expected outcomes. Staffing included RNs, LPNs, and OMTs, but medication training for OMTs by RNs was lacking, and orientation checklists were not signed by RNs. Tenants expressed some complaints about food quality and dining atmosphere but felt safe and well cared for.
Complaint Details
No substantiated complaints this certification period.
Deficiencies (2)
| Description |
|---|
| The program did not have a service plan that addressed tenant outcomes. |
| The program did not have appropriately trained staff. |
Report Facts
Current number of tenants without cognitive disorder: 11
Current number of tenants with cognitive disorder: 4
Total Population: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | SW | Monitor conducting the evaluation |
| Tom Knoepke | Executive Director | Facility leadership mentioned in report |
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