Inspection Reports for Gardens of Cedar Rapids
5710 Dean Road SW, Cedar Rapids, IA, 52404
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 17, 2025, identified deficiencies related to incomplete incident reporting and inadequate updating of service plans for tenants’ needs, including pressure wounds and skin issues. Earlier inspections showed a pattern of issues with service plans, documentation, medication administration, and staff training, with prior complaint investigations substantiating medication errors that led to a tenant’s hospitalization. Inspectors cited problems mainly in service planning, incident reporting, medication management, and staff training. Complaint investigations included one substantiated case involving medication errors and hospital admission, while other complaints focused on documentation and care concerns. The facility’s deficiencies have persisted over time with similar themes, indicating ongoing challenges in fully meeting regulatory requirements.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
32% better than Iowa average
Iowa average: 4.4 deficiencies/year
Deficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
29 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 29
Deficiencies: 2
Date: Mar 17, 2025
Visit Reason
The inspection was a recertification visit to determine compliance with certification rules for an Assisted Living Program.
Findings
The program failed to follow its policies and procedures related to incident reports and service plans. Specifically, an incident report was not completed for a tenant with suicidal ideation, and service plans did not adequately reflect tenants' identified needs and services, including pressure wounds and skin issues.
Deficiencies (2)
Program failed to follow its policy and procedure related to incident reports, specifically for a tenant with a history of suicidal ideations.
Program failed to update service plans as needed and failed to have service plans that reflected the service needs of tenants, including pressure wounds and skin issues.
Report Facts
Number of tenants without cognitive impairment: 27
Number of tenants with cognitive impairment: 2
Total census: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assisted Living Director | Confirmed incident report was not completed and confirmed service plans did not reflect specific tenant conditions | |
| Executive Director | Signed the inspection report on 4/15/2025 |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 6
Date: May 18, 2022
Visit Reason
The investigation of Complaint #104625-C and the recertification visit were conducted to determine compliance with certification for an Assisted Living Program.
Complaint Details
Complaint #104625-C was investigated as part of the visit. The complaint involved concerns about tenant care, documentation, and occupancy agreement compliance.
Findings
The Program failed to provide adequate and appropriate services related to meals for a tenant with special dietary needs, failed to document nurse delegated training for insulin administration for some staff, did not follow the terms of the executed occupancy agreement regarding security deposits for a discharged tenant, failed to document nurse's notes by exception for several tenants, failed to develop service plans based on evaluations and identified needs for some tenants, and failed to ensure staff completed annual food safety training.
Deficiencies (6)
Failed to provide services that were adequate and appropriate related to meals for 1 of 1 tenants reviewed with special dietary needs (Tenant #4).
Failed to document nurse delegated training for insulin administration for 2 of 3 staff reviewed who administered medications (Staff B and D).
Failed to follow the terms of the executed occupancy agreement regarding security deposits for 1 of 2 discharged tenants reviewed (Tenant C2).
Failed to document nurse's notes by exception for 2 of 4 current tenants reviewed (Tenants #1 and #4) and 2 of 2 discharged tenants reviewed (Tenant C1 and Tenant C2).
Failed to develop service plans based on evaluations and identified needs of 2 of 4 current tenants reviewed (Tenants #1 and #2).
Failed to have staff complete an annual training on food protection for 1 of 1 staff reviewed (Staff D).
Report Facts
Number of tenants without cognitive disorder: 17
Number of tenants with cognitive disorder: 4
Total census: 21
Security deposit amount: 1500
Refund check amounts: 84.6
Refund check amounts: 1415.4
Staff hire date: 2020
Food safety training date: 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Staff who administered insulin but lacked documented nurse delegated training. | |
| Staff D | Staff who administered insulin and was overdue for annual food safety training. | |
| Samantha Gaspar | Executive Director | Signed Plan of Correction and confirmed findings during interview. |
| Director of Nursing | Director of Nursing | Provided interviews and confirmed findings related to nursing documentation and staff training. |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 1
Date: Mar 5, 2020
Visit Reason
The inspection was conducted to investigate Complaint #88243-C and to determine compliance with certification for an Assisted Living Program.
Complaint Details
Investigation of Complaint #88243-C revealed medication administration errors involving fentanyl patches, including incorrect dosages and administration without proper verification. Tenant #2 was hospitalized due to these errors. The complaint was substantiated by these findings.
Findings
The program failed to administer medications as ordered by tenants' physicians for 2 of 4 tenants reviewed, including errors in fentanyl patch dosages and administration. The pharmacy sent a prescription with the wrong tenant's name, leading to medication errors and a hospital visit for one tenant.
Deficiencies (1)
Failure to administer medications as prescribed by tenants' physicians, including incorrect fentanyl patch dosages and administration errors for tenants #1 and #2.
Report Facts
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 0
Total census of Assisted Living Program: 27
Number of tenants reviewed for medication administration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jenna Gardner | Executive Director | Signed the Plan of Correction letter dated April 29, 2020. |
Report
Jan 9, 2025
Report
Jan 9, 2025
Report
Aug 16, 2024
Report
Mar 14, 2024
Report
Sep 7, 2023
Report
Jan 18, 2023
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