Inspection Reports for Stoney Point Meadows
1900 Stoney Point Road SW, Cedar Rapids, IA, 52404
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 7, 2025, found deficiencies related to incident report policies for tenants with bruising and updating service plans to reflect tenant needs and medication management. Earlier inspections identified similar issues with service plan updates, staff training, and response to alarms, as well as failures in following policies for incident reporting and dementia-specific education. Complaint investigations included a substantiated case involving delayed staff response after a fall that resulted in serious injury, but most other complaints were unsubstantiated. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history shows recurring themes around service plan accuracy and staff adherence to policies, with no clear pattern of improvement or worsening over time.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
2.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
41% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
94 residents
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 94
Deficiencies: 2
Date: Apr 7, 2025
Visit Reason
The visit was conducted as a recertification visit to determine compliance with certification of a Dedicated Dementia Specific Assisted Living Program. The inspection also investigated Complaint #125163-C but found no regulatory insufficiencies related to it.
Complaint Details
There were no regulatory insufficiencies cited related to the investigation of Complaint #125163-C.
Findings
The inspection found deficiencies related to program policies and procedures, specifically failure to follow incident report policies for tenants with bruising, and failure to update service plans to reflect tenant needs and medication management. Corrective actions including re-education of nursing staff were planned.
Deficiencies (2)
Program failed to follow its policy and procedure related to the completion of incident reports for tenants with bruising.
Program failed to update service plans as needed to reflect the needs of tenants, including medication management.
Report Facts
Number of tenants without cognitive impairment: 77
Number of tenants with cognitive impairment: 17
Total census: 94
Tenants reviewed for incident report compliance: 8
Tenants reviewed for service plan compliance: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health Services | Director of Health Services | Confirmed no incident report was completed related to Tenant #7's bruising and confirmed medication management was not reflected on Tenant #1's service plan. |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 1
Date: Sep 28, 2023
Visit Reason
The inspection was conducted to investigate complaints and incidents, including Incident #113467-I involving a fall and injury of Tenant #1 in the memory care unit.
Complaint Details
The investigation of Incident #113467-I found the motion sensor alerted staff at 2:42 a.m., but staff did not check on Tenant #1 until approximately 20 minutes later. Tenant #1 suffered a subdural hemorrhage and was admitted to hospice care. No deficiencies were cited in investigations of Complaint #111413-C, #113390-C, or Incident #113700-I.
Findings
The program failed to follow established policies and procedures regarding motion sensor alarms for one tenant, resulting in delayed staff response to a fall that caused serious injury. No regulatory insufficiencies were found in other complaint investigations.
Deficiencies (1)
Failure to follow established policies and procedures regarding motion sensor alarms for Tenant #1, leading to delayed staff response after a fall.
Report Facts
Number of tenants without cognitive impairment: 70
Number of tenants with cognitive impairment: 18
Total census: 88
Motion sensors in Memory Care rooms: 14
Staples required for laceration: 12
Falls by Tenant #1 since 12/30/22: 6
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 5
Date: Jul 19, 2022
Visit Reason
The investigation of Incident #98416-I and Complaint #105445-C and the recertification visit to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program were completed.
Complaint Details
The visit was complaint-related involving Incident #98416-I and Complaint #105445-C. The complaint included concerns about incident reporting failures and delayed pendant response times. The complaint was substantiated as deficiencies were identified.
Findings
The program failed to follow its policies related to incident reports and prompt response to pendants, failed to ensure staff provided services according to training, failed to update service plans as needed for multiple tenants, and failed to ensure dementia-specific education requirements were met for staff.
Deficiencies (5)
Failed to follow policy related to incident reports for multiple tenants and failed to respond promptly to pendants.
Failed to ensure staff provided services in accordance with training, specifically improper disposal of lancets during blood glucose checks.
Failed to update service plans as needed for 5 of 7 tenants reviewed.
Failed to ensure eight hours of dementia-specific education was completed within 30 days of employment for 3 of 8 staff reviewed.
Failed to include two hours of hands-on dementia-specific training for 5 of 5 staff who completed eight hours of dementia-specific education within 30 days of employment.
Report Facts
Census: 75
Pendant response times: 19.77
Pendant response times: 24.57
Pendant response times: 47.13
Pendant response times: 38.83
Pendant response times: 15.85
Staff reviewed for dementia education compliance: 8
Staff lacking 8 hours dementia education within 30 days: 3
Staff lacking hands-on dementia training: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Failed to complete incident report properly and failed to dispose lancet correctly during blood glucose check; lacked dementia-specific education within 30 days. | |
| Staff G | Lacked dementia-specific education within 30 days. | |
| Staff H | Lacked dementia-specific education within 30 days. | |
| Staff A | Completed dementia-specific education but lacked documented hands-on training. | |
| Staff B | Completed dementia-specific education but lacked documented hands-on training. | |
| Staff C | Completed dementia-specific education but lacked documented hands-on training. | |
| Staff E | Completed dementia-specific education but lacked documented hands-on training. | |
| Staff F | Completed dementia-specific education but lacked documented hands-on training. | |
| Director of Health Services | Interviewed and confirmed findings related to incident reporting, staff training, and service plan deficiencies. | |
| Director of Housing | Confirmed findings related to dementia education and pendant response policy. |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Date: Dec 22, 2020
Visit Reason
The inspection was conducted as an investigation of Complaint #91721-C related to regulatory insufficiencies in service plans at Stoney Point Meadows.
Complaint Details
Complaint #91721-C was investigated. The findings showed the complaint was substantiated due to failure in service plan compliance and tenant care issues.
Findings
The program failed to ensure service plans were based on evaluations and included all identified needs for 5 of 5 current tenants and 1 former tenant reviewed. Multiple tenants' service plans did not address risks such as falls, use of assistive devices, incontinence, and behavioral issues. Tenant C-1 exhibited aggressive and unsafe behaviors, and her service plan was not updated to reflect changes in condition or behavior.
Deficiencies (1)
Failure to develop service plans based on evaluations and to include all identified needs for tenants.
Report Facts
Total Census: 49
Tenants without cognitive disorder: 38
Tenants with cognitive disorder: 0
Tenants without cognitive disorder: 0
Tenants with cognitive disorder: 11
Tenants reviewed for service plans: 6
Inspection Report
Original Licensing
Census: 26
Deficiencies: 4
Date: Oct 22, 2019
Visit Reason
The inspection was conducted as an initial certification visit to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Findings
The inspection found regulatory insufficiencies related to incomplete background checks for staff prior to employment and failure to develop individualized service plans reflecting tenant needs. Additionally, the program lacked an operating alarm system connected to each exit door in the dementia-specific program.
Deficiencies (4)
Failed to complete background checks prior to employment for staff.
Failed to obtain evaluation by Department of Human Services to determine if employment was prohibited for staff with a criminal history.
Failed to develop individualized service plans reflecting identified tenant needs and preferences.
Failed to have an operating alarm system connected to each exit door in the dementia-specific program.
Report Facts
Number of tenants without cognitive disorder in general population: 21
Number of tenants with cognitive disorder in general population: 0
Number of tenants without cognitive disorder in memory care unit: 0
Number of tenants with cognitive disorder in memory care unit: 5
Total census of Assisted Living Program for People with Dementia: 26
Staff reviewed for background checks: 8
Staff A date of hire: 2019
Staff B date of hire: 2019
Date of record check for Staff A: 2019
Date of record check for Staff B: 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Staff member whose background check was incomplete prior to employment | |
| Staff B | Staff member whose DHS evaluation for employment prohibition was not obtained prior to employment | |
| Director of Housing | Director of Housing | Interviewed regarding background check information for Staff A and Staff B |
| Director of Health Services | Director of Health Services | Provided information on service plans and corrections made |
| Maintenance Director | Maintenance Director | Interviewed regarding front entrance door security and alarm system |
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