Inspection Reports for Prairie Hills at Cedar Rapids

The inspection was conducted related to the investigation of Complaints #126260-C and #127806-C and the recertification visit to determine compliance with certification as an Assisted Living Program.

The Program failed to follow established policies and procedures related to medication administration, incident reporting, abuse policy, and documentation of tasks. Deficiencies were found in wound care documentation, incident reporting, nurse delegation, tenant evaluations, service plans, nurse reviews, and food temperature control.

The visit was complaint-related involving allegations of abuse and failure to follow policies and procedures. Tenant C1 alleged staff roughness and bruising during transfer, which was not properly documented or investigated.

The inspection was conducted as an investigation of Incident #115284-I involving allegations of dependent adult abuse and inadequate care at Prairie Hills at Cedar Rapids.

The program failed to have a policy consistent with Iowa Code chapter 235E requiring separation of victim and alleged abuser, potentially affecting all 43 tenants. Additionally, Staff A was found to have verbally abused and neglected care duties for three tenants, including refusal to assist with toileting and transfers, yelling at tenants, and instructing tenants not to call for help, leading to Staff A's suspension and termination.

The investigation was triggered by allegations of verbal abuse and neglect by Staff A towards Tenant #1, Tenant C1, and Tenant C2. The complaint was substantiated based on staff statements, tenant interviews, video evidence, and internal investigation. Staff A was suspended pending investigation and subsequently terminated for violating the Dependent Adult Abuse Policy.

Investigation of Complaint #115034-C at Prairie Hills at Cedar Rapids.

No regulatory insufficiencies were cited during the investigation.

Complaint #115034-C was investigated and found to have no regulatory insufficiencies.

The inspection was conducted during the investigation of Complaints #105632-C and #109460-C and the recertification visit to determine compliance with certification rules for an Assisted Living Program.

The Program failed to follow multiple policies and procedures including insulin administration, medication administration, incident report completion, and the Drug and Alcohol policy. Medication errors were identified for multiple tenants, including administration of insulin despite blood glucose parameters, administration of discontinued medications, and administration of medications from the wrong medication planner. Evaluations and service plans were not completed or updated as required. Nurse's notes were not documented by exception for a hospitalized tenant. Food service staff did not receive timely orientation on sanitation and safe food handling.

The visit was complaint-related, investigating Complaints #105632-C and #109460-C. The complaints involved medication errors, policy violations, and possible unauthorized drug activity by staff.

Investigation of Complaint #98357-C at Prairie Hills Senior Living.

No regulatory insufficiencies were cited during the investigation of the complaint.

Complaint #98357-C was investigated and found to have no regulatory insufficiencies.

The inspection was conducted as an investigation of Incident #98189-I involving a tenant's suicide attempt at Prairie Hills Senior Living.

The program failed to notify the Department within 24 hours or the next business day of the tenant's suicide attempt, despite evidence from interviews and record reviews. The tenant took approximately 97 tablets of medication and was admitted to the hospital for monitoring and psychiatric evaluation.

Investigation of Incident #98189-I regarding a tenant's suicide attempt. The incident was substantiated as the program did not report the event timely to the Department.

The inspection was conducted as a recertification visit to determine compliance with certification for an Assisted Living Program and to investigate Complaint #93272-C, including an on-site infection control survey.

The facility was found to have regulatory insufficiencies related to program policies and procedures, tenant rights, and staffing. Specifically, failures were noted in following incident report policies, providing adequate care and treatment to two tenants, and ensuring nurse delegation training compliance among staff.

Complaint #93272-C was investigated during the recertification visit and on-site infection control survey. The complaint involved incidents with two tenants, including falls and inadequate care. The complaint was substantiated as evidenced by the cited deficiencies.

The inspection was conducted as an onsite infection control survey and investigation of Complaint #91786-C regarding regulatory insufficiencies at Prairie Hills Senior Living.

No regulatory insufficiencies were cited during the infection control survey; however, deficiencies were found related to failure to provide written occupancy agreements, inadequate tenant rights protections, failure to provide adequate and appropriate care and services, incomplete tenant evaluations, and failure to update service plans as needed.

Complaint #91786-C was investigated from July 21, 2020 through October 7, 2020. The complaint involved issues with occupancy agreements, tenant rights, care and services, tenant evaluations, and service plans.

The inspection was a recertification visit conducted to determine compliance with certification for an Assisted Living Program.

The program failed to ensure staff received nurse delegated training for nephrostomy tube site dressing changes and failed to develop service plans reflecting tenants' identified needs. Deficiencies were cited related to staffing and service plans.

Investigation of Complaint #63043-C regarding the Assisted Living Program at Prairie Hills at Cedar Rapids.

No regulatory insufficiencies were cited during the complaint investigation. The census included 44 tenants without cognitive disorder and 3 tenants with cognitive disorder, totaling 47 residents.

Complaint #63043-C was investigated and found to have no regulatory insufficiencies.

The inspection was conducted as a Final Recertification and Complaint/Incident Investigation visit for Prairie Hills at Cedar Rapids, Iowa, including investigation of Incident #58983-I.

There was a regulatory insufficiency identified related to program policies and procedures during the recertification visit. The complaint allegation was unsubstantiated with no regulatory insufficiencies related to the incident investigation.

Allegation: Department of Inspections and Appeals (DIA) notification. Findings: Unsubstantiated. Review of tenant file, staff interviews, tenant interview, and program documents did not reveal a regulatory insufficiency related to DIA notification.

The inspection was conducted as a complaint/incident investigation based on tenant observations, staff interviews, and review of various records including medication administration and incident reports.

No regulatory insufficiencies were identified. All allegations regarding level of care, policy and procedure, and medication management were found to be not substantiated.

Allegations included level of care, policy and procedure, and medication management. All findings were not substantiated based on tenant observations, staff interviews, and record reviews.

The visit was a Final Recertification Monitoring Evaluation conducted to review recertification documents and evaluate compliance with Iowa Administrative Code for the Assisted Living Program at Prairie Hills at Cedar Rapids.

No regulatory insufficiencies were found during the evaluation. The review of submitted documents was completed and accepted, and the State Fire Marshal's inspection report and Facility Engineer's approval of evacuation plans were received.

The visit was a final recertification monitoring evaluation conducted to assess compliance with Iowa Code and Administrative Code for the Assisted Living Program at Prairie Hills at Cedar Rapids.

No regulatory insufficiencies were found during the onsite recertification monitoring evaluation. The program did not receive any regulatory insufficiencies during this certification period.

The visit was conducted as a Final Incident Investigation and Recertification Monitoring Evaluation following complaints regarding missing medications at Brook View Senior Living.

The investigation found that two tenants reported missing medications, but it could not be determined who took the medications. No regulatory insufficiencies were noted related to the medication incidents. The program had a bus without adequate seat belts, which was cited as a regulatory insufficiency.

Two incident allegations were investigated: Tenant #1 reported missing Hydrocodone/Apap 2.5/500 mg and Tenant #2 reported missing Darvocet between October 28, 2010 and November 11, 2010. Both tenants self-administered medications. Despite investigation, it could not be determined who took the medications. Staff and administration did not know who took the medications. No regulatory insufficiencies were noted related to these complaints.

The visit was conducted as a final incident investigation regarding an employee admitted to taking medication belonging to a tenant at BrookView Senior Living.

The investigation found that an employee admitted to stealing medication from a tenant. The tenant was administered new medication at no cost, the theft was reported to the Department, and the employee was suspended and later terminated. No regulatory insufficiencies were identified.

The complaint involved an employee admitted to taking medication belonging to a tenant. The allegation was substantiated by the employee's admission and subsequent actions taken by the facility.

An on-site monitoring evaluation was conducted at BrookView Senior Living to review the facility's compliance with assisted living program regulations and the Plan of Correction submitted in response to the Initial Certification Monitoring Evaluation.

The evaluation found no substantiated regulatory insufficiencies during the certification period. Tenant satisfaction was generally positive with some concerns noted about dining services and communication. A regulatory insufficiency was identified related to the occupancy agreement not consistently including all required fee and service descriptions.