Inspection Reports for Cottage Grove Place – Connections
2115 1st Avenue SE, Cedar Rapids, IA, 52402
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 17, 2025, identified deficiencies related to incident report policies, medication administration, tenant evaluations, and updating service plans. Earlier inspections showed similar issues with documentation, staff training, and tenant care, including failure to complete evaluations timely and incomplete incident reporting. Complaint investigations substantiated concerns about regulatory compliance, staff training, and safety measures such as door alarms and confidentiality. Enforcement actions such as fines or license suspensions were not listed in the available reports. The pattern of deficiencies has persisted over time without clear improvement.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
14 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: 14
Deficiencies: 5
Date: Sep 17, 2025
Visit Reason
The inspection was a recertification visit conducted to determine compliance with certification of a Dedicated Dementia Specific Assisted Living Program.
Findings
The facility was found deficient in several areas including failure to include witness statements in incident report policies, failure to administer medications as prescribed for 2 of 3 tenants reviewed, failure to complete tenant evaluations within 30 days of occupancy, and failure to update service plans to reflect tenant needs and changes for 3 tenants reviewed.
Deficiencies (5)
Program incident report policy and procedure failed to include statements from individuals who witnessed the incident.
Failed to administer medication and treatments as prescribed by the tenant's physician for 2 of 3 tenants reviewed.
Failed to complete tenant evaluations within 30 days of occupancy for 1 of 1 tenant reviewed.
Failed to update service plans as needed and failed to have service plans reflect the service needs of tenants for 3 of 3 tenants reviewed.
Failed to update service plans within 30 days of taking occupancy for 1 of 1 tenant reviewed.
Report Facts
Tenants without cognitive impairment: 4
Tenants with cognitive impairment: 10
Total census: 14
Medication not administered due to unavailability: 10
Medication not administered due to unavailability: 1
Medication not administered due to unavailability: 12
Medication not administered due to unavailability: 13
Falls for Tenant #1: 3
Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 7
Date: May 3, 2023
Visit Reason
The inspection was conducted as part of the investigation of Complaint #108624-C and the recertification visit to determine compliance with certification of a Dedicated Dementia Specific Assisted Living Program.
Complaint Details
The visit was triggered by Complaint #108624-C, which involved investigation of incidents between tenants and concerns about staff posting tenant information on social media.
Findings
The Program failed to follow its policies and procedures, including failure to complete incident reports related to tenant incidents, failure to obtain signed occupancy agreements prior to tenant occupancy, failure to document nurse's notes by exception, failure to develop service plans reflecting tenant needs, and failure to ensure staff received required dementia-specific education and training.
Deficiencies (7)
Failure to follow program policies and procedures including incident reporting and social media confidentiality.
Failure to obtain signed occupancy agreements prior to tenant occupancy.
Failure to document nurse's notes by exception for current and discharged tenants.
Failure to develop service plans that reflect the specific service needs of tenants.
Failure to ensure staff received eight hours of dementia-specific education within 30 days of employment.
Failure to ensure staff received eight hours of dementia-specific continuing education annually.
Failure to provide hands-on dementia-specific training for staff.
Report Facts
Total census: 16
Number of tenants without cognitive impairment: 2
Number of tenants with cognitive impairment: 14
Number of tenants reviewed: 3
Number of discharged tenants reviewed: 2
Number of staff reviewed for dementia training: 4
Number of staff lacking timely dementia training: 2
Number of staff lacking annual dementia training: 1
Number of staff lacking hands-on dementia training: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in findings related to social media policy violation, dementia training deficiencies, and tenant behavior management. | |
| Staff B | Named in dementia training deficiency for not completing 8 hours within 30 days of employment. | |
| Staff C | Named in dementia training deficiency for not completing 8 hours within 30 days of employment. | |
| Staff D | Named in dementia training deficiency for lack of hands-on training. | |
| Staff E | Named in dementia training deficiency for lack of hands-on training. | |
| Assisted Living Administrator | Interviewed and provided confirmation of training and policy compliance status. | |
| Assisted Living Director of Nursing | DON | Involved in tenant care assessments and education of staff on incident reporting. |
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 2
Date: Mar 23, 2021
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #94412-C and Incident #94539-I, focusing on regulatory insufficiencies identified during an infection control survey and tenant evaluations.
Complaint Details
Complaint #94412-C and Incident #94539-I were investigated. The complaint was substantiated as regulatory insufficiencies were identified related to tenant evaluations and life safety emergency policies.
Findings
The program failed to complete required tenant evaluations within 30 days of occupancy and after significant changes, and did not have an operating door alarm system connected to each exit door in the dementia-specific assisted living program. Tenant #1 left the facility without staff knowledge, exposing safety risks.
Deficiencies (2)
Failure to complete tenant evaluations within 30 days of occupancy and after significant changes for tenants with cognitive decline.
Failure to have an operating door alarm system connected to each exit door in the dementia-specific assisted living program.
Report Facts
Number of tenants without cognitive disorder: 4
Number of tenants with cognitive disorder: 6
Total census: 10
Date of tenant file record review: Mar 23, 2021
Date of incident: Oct 31, 2020
Date keypad installed: Nov 4, 2020
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 7
Date: Oct 15, 2020
Visit Reason
The investigation of Complaint #93873-C was completed along with the initial certification visit to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Complaint Details
Investigation of Complaint #93873-C was completed to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Findings
The program failed to follow established policies and procedures regarding incident reports, including the inclusion of witness statements. Evaluations and documentation for tenants were incomplete or missing, and staff training and competency reviews were not completed timely. Several deficiencies related to tenant care, staff training, and documentation were identified.
Deficiencies (7)
Program failed to follow established policy and procedure regarding the completion of incident reports including witness statements.
Program failed to complete evaluations as needed with significant change for tenants.
Program failed to ensure staff were trained and competent within 60 days of new delegating nurse employment.
Program failed to complete orientation on sanitation and safe food handling prior to handling food for staff.
Program failed to complete background check prior to employment for one staff member.
Program failed to ensure staff completed eight hours of dementia specific education and training within 30 days of employment.
Program failed to update service plans within 30 days of tenant occupancy or significant change.
Report Facts
Number of tenants without cognitive disorder: 4
Number of tenants with cognitive disorder: 6
Total census: 10
Date of survey completed: Oct 15, 2020
Inspection Report
Routine
Census: 10
Deficiencies: 0
Date: Jul 30, 2020
Visit Reason
The inspection was conducted as an onsite infection control survey for the Assisted Living Program serving people with dementia.
Findings
There were no regulatory insufficiencies cited during the onsite infection control survey completed on 7/30/2020.
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