Inspection Report Summary
The most recent inspection on October 21, 2025 found the facility to be in substantial compliance with no deficiencies. Earlier inspections showed a pattern of deficiencies related mainly to medication management, abuse prevention policies, and resident care, including treatment of skin breakdown and pressure ulcers. Complaint investigations included substantiated findings for failure to provide appropriate interventions and follow physician orders, but enforcement actions such as fines or license suspensions were not listed in the available reports. Most complaints were substantiated, particularly those involving resident care and medication issues, while some investigations found the facility in substantial compliance. The facility’s record shows some improvement over time, with recent inspections indicating correction of prior deficiencies and compliance with regulatory requirements.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
123% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
35 residents
Based on a January 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 21, 2025
Visit Reason
A complaint investigation for facility reported incident #2642387 was conducted.
Complaint Details
Complaint investigation for incident #2642387; facility found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 4, 2025
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance and will be certified in compliance effective January 31, 2025.
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 5
Date: Jan 9, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey and investigation of facility reported incidents from January 6 to January 9, 2025.
Findings
The facility was found not in compliance with requirements related to abuse prevention, misappropriation of resident medications, and controlled substance management. Deficiencies were identified in medication administration records, narcotic counts, and staff adherence to policies. The facility failed to implement adequate abuse prevention policies and failed to report and investigate alleged violations properly.
Deficiencies (5)
Failure to prevent misappropriation of resident medications and failure to implement abuse prevention policies.
Failure to report alleged violations timely and thoroughly investigate abuse, neglect, exploitation, and misappropriation.
Failure to accurately account for controlled/narcotic medications and reconcile discrepancies.
Failure to label and store drugs and biologicals properly under secure conditions.
Failure to provide influenza and pneumococcal immunizations according to CDC guidelines.
Report Facts
Census: 35
Deficiencies cited: 5
Morphine remaining: 24
Morphine remaining: 8.75
Morphine remaining: 29.5
Controlled substance count discrepancies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) / Registered Nurse (RN) | Named in findings related to narcotic count discrepancies and medication administration |
| Staff D | Registered Nurse (RN) | Named in findings related to narcotic count discrepancies and reporting concerns |
| Staff B | Director of Nursing (DON) | Named in findings related to failure to report narcotic discrepancies and abuse allegations |
| Staff C | Licensed Practical Nurse (LPN) | Named in findings related to medication administration and observation of Staff A |
| Staff E | Certified Nurses Aid (CNA) | Named in findings related to medication administration and observation of Staff A |
| Staff H | Registered Nurse (RN) | Named in findings related to medication administration and narcotic count |
| Staff I | Licensed Practical Nurse (LPN) | Named in findings related to narcotic count and medication administration |
| Director of Nursing | Director of Nursing (DON) | Named in findings related to narcotic count discrepancies and reporting |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 6
Date: Jan 9, 2025
Visit Reason
The investigation was conducted due to reported misappropriation and diversion of controlled/narcotic medications for three residents, triggered by discrepancies in narcotic counts and staff behavior concerns.
Complaint Details
The complaint investigation was triggered by narcotic medication count discrepancies for Residents #89 and #90, concerns about Staff A's behavior indicating possible impairment, and failure of the facility to report and investigate the incidents properly.
Findings
The facility failed to prevent drug diversion for 3 residents, failed to implement abuse prevention policies properly, failed to timely report suspected abuse and misappropriation to authorities, failed to investigate the incidents adequately, and failed to securely store medications. Multiple discrepancies in narcotic medication counts were documented, and staff behavior raised concerns about impairment during shifts.
Deficiencies (6)
Failed to prevent drug diversion for 3 residents' controlled/narcotic medications.
Failed to implement abuse prevention policies for investigation into reported misappropriated resident medications for 2 residents.
Failed to timely report misappropriation of medications for 2 residents to State Agency and law enforcement.
Failed to investigate reported incident of misappropriated resident medications for 2 residents and failed to prevent further misappropriation for 1 resident.
Failed to accurately account for controlled/narcotic medications for 3 residents.
Failed to securely store medications; medication cart left unlocked in lounge area with residents nearby.
Report Facts
Residents affected: 3
Census: 35
Morphine missing amount: 2
Morphine missing amount: 2.25
Medication signed out times: 4
Medication signed out times: 4
Ativan discrepancy: 2
Medication cart unlocked times: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in multiple findings related to narcotic medication diversion, documentation discrepancies, and impaired behavior during shifts. |
| Staff D | Registered Nurse (RN) | Reported narcotic count discrepancies, refused to sign inaccurate counts, alerted Director of Nursing, and described Staff A's impaired behavior. |
| Staff B | Director of Nursing (DON) | Failed to identify concerns timely, failed to report narcotic discrepancies, received alerts from staff, and expected accurate narcotic counts. |
| Staff C | Licensed Practical Nurse (LPN) | Reported Staff A's impaired behavior, assisted Staff A to rest, and described medication room observations. |
| Staff E | Certified Nurses Aid (CNA) | Reported Staff A's impaired behavior and called Chief Operating Officer. |
| Staff I | Licensed Practical Nurse (LPN) | Signed narcotic counts, confirmed accurate dosing, and reported procedures for narcotic counts. |
| Staff H | Registered Nurse (RN) | Reported E-kit locked and secure, no discrepancies known. |
| Staff K | Licensed Practical Nurse (LPN) | Observed medication cart unlocked, reported normally does not leave cart unlocked. |
| Staff L | Chief Executive Officer (CEO) | Reported previous DON failed to report narcotic count discrepancies to Administrator. |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 7
Date: Jan 9, 2025
Visit Reason
The inspection was conducted due to complaints and concerns regarding drug diversion, misappropriation of resident medications, and failure to implement abuse prevention policies at The Gardens of Cedar Rapids nursing home.
Complaint Details
The investigation was complaint-driven based on reports of drug diversion, medication misappropriation, and failure to follow abuse prevention and reporting policies. Staff interviews and video surveillance revealed a nurse (Staff A) diverting narcotic medications and exhibiting impaired behavior. The facility failed to report and investigate these incidents timely and adequately.
Findings
The facility failed to prevent drug diversion for 3 residents, failed to implement abuse prevention policies and timely report suspected abuse, and failed to investigate reported incidents of medication misappropriation. Additionally, the facility failed to securely store medications and accurately account for controlled substances. One resident was not offered pneumococcal vaccination according to CDC guidelines.
Deficiencies (7)
Failed to prevent drug diversion for 3 residents' controlled/narcotic medications.
Failed to implement abuse prevention policies for investigation into reported misappropriated resident medications for 2 residents.
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities for 2 residents.
Failed to respond appropriately to all alleged violations including investigation of misappropriated resident medications and prevention of further misappropriation.
Failed to accurately account for controlled/narcotic medications for 3 residents.
Failed to securely store medications on medication carts on multiple occasions.
Failed to offer pneumococcal vaccinations according to CDC guidelines for 1 resident.
Report Facts
Residents affected: 3
Census: 35
Morphine missing: 2
Morphine missing: 2.25
Ativan missing: 2
Medication signed out: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in findings related to drug diversion, impaired behavior, and failure to report discrepancies. |
| Staff D | Registered Nurse (RN) | Reported discrepancies in narcotic counts and refusal to sign count sheets; observed Staff A's impaired behavior. |
| Staff B | Director of Nursing (DON) | Failed to identify concerns timely and failed to report inaccurate narcotic counts to Administrator. |
| Staff I | Licensed Practical Nurse (LPN) | Signed narcotic counts and confirmed accuracy of medication amounts. |
| Staff C | Licensed Practical Nurse (LPN) | Observed Staff A's impaired behavior and assisted her to rest. |
| Staff E | Certified Nurses Aid (CNA) | Reported Staff A's impaired behavior and notified Chief Operating Officer. |
| Staff H | Registered Nurse (RN) | Reported E-kit locked and secure; worked 6 AM to 2 PM shift on 9/19/24. |
| Staff L | Chief Executive Officer (CEO) | Reported previous DON failed to report narcotic count discrepancies. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 10, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance and will be certified effective September 4, 2024, based on the Plan of Correction submitted.
Inspection Report
Routine
Census: 36
Deficiencies: 1
Date: Aug 16, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with providing appropriate treatment and care according to physician orders, resident preferences, and goals, specifically related to skin breakdown and wound care for Resident #3.
Findings
The facility failed to provide interventions and treatments for one resident with multiple skin wounds and failed to obtain timely physician orders for wound care. The Director of Nursing delayed obtaining and transcribing physician orders, resulting in a gap in treatment orders from 7.24.24 to 7.28.24.
Deficiencies (1)
Failure to provide interventions/treatments for 1 of 3 residents with skin breakdown and failure to obtain physician's orders for 1 of 3 residents reviewed.
Report Facts
Census: 36
Skin/wound measurements: 6
Skin/wound measurements: 8
Skin/wound measurements: 0.2
Skin/wound measurements: 9.5
Skin/wound measurements: 8
Skin/wound measurements: 0.2
Skin/wound measurements: 18
Skin/wound measurements: 28
Skin/wound measurements: 0.3
Skin/wound measurements: 20
Skin/wound measurements: 32
Skin/wound measurements: 0.3
Skin/wound measurements: 2
Skin/wound measurements: 1
Skin/wound measurements: 3
Skin/wound measurements: 2
Skin/wound measurements: 0.2
Skin/wound measurements: 0.8
Skin/wound measurements: 1
Skin/wound measurements: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Reported inability to locate treatment orders on resident's MAR and TAR |
| Director of Nursing (DON) | Director of Nursing | Faxed admission wound measurements to physician and confirmed backdating of orders |
| Staff B | Licensed Practical Nurse (LPN) / Admission and Wound Care Nurse | Performed admission assessment and addressed resident's wounds |
| Staff C | RN/Corporate Nurse Consultant | Confirmed expectation that nurses obtain physician orders for wounds |
| Interim Administrator | Interim Administrator | Confirmed communication about missing treatment orders and follow-up with DON |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 1
Date: Aug 15, 2024
Visit Reason
The inspection was conducted as a complaint investigation (#122479-C) from August 15-16, 2024, focusing on quality of care concerns related to treatment and physician orders for a resident with skin breakdown.
Complaint Details
Investigation of complaint #122479-C conducted August 15-16, 2024. The complaint was substantiated based on failure to provide treatment and obtain physician orders for a resident with skin breakdown.
Findings
The facility failed to provide appropriate interventions and treatments for one of three residents with skin breakdown and failed to obtain physician's orders for that resident. The deficiencies were documented with clinical record reviews, observations, and staff interviews.
Deficiencies (1)
Failure to provide interventions/treatments for 1 of 3 residents with skin breakdown and failure to obtain physician's orders for that resident.
Report Facts
Resident census: 36
Dates of complaint investigation: 2024-08-15 to 2024-08-16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Informed about missing treatment orders via telephone call |
| Staff B | Licensed Practical Nurse (LPN) / Admission and Wound Care Nurse | Performed admission assessment and addressed wounds |
| Staff C | RN / Corporate Nurse Consultant | Confirmed expectation for nurses to obtain physician orders |
| Interim Administrator | Confirmed missing physician orders and communication issues | |
| Director of Nursing (DON) | Director of Nursing | Confirmed backdating of physician orders and nursing standards |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 4, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on April 4, 2024.
Findings
Based on acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, the facility will be certified in compliance effective April 4, 2024.
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 3
Date: Mar 14, 2024
Visit Reason
An annual recertification survey was conducted from March 11, 2024 to March 14, 2024 to assess compliance with regulatory requirements at The Gardens of Cedar Rapids.
Findings
The facility was found to be in substantial compliance overall, but deficiencies were cited related to failure to develop and implement abuse/neglect policies, failure to provide bed hold notices before transfers for some residents, and inadequate catheter care leading to infection control concerns.
Deficiencies (3)
Failure to develop and implement written policies and procedures to prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.
Failure to provide notice of bed hold policy and bed hold notice upon transfer to residents or their representatives for 2 of 2 residents sampled.
Failure to provide appropriate catheter care when urinary drainage bag and tubing contacted the floor, risking infection for 1 of 1 residents sampled.
Report Facts
Census: 31
Deficiencies cited: 3
Resident sample size: 2
Resident sample size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant | Named in deficiency related to lack of Department of Criminal Investigation clearance |
| Sadie Mason | Administrator | Reported on employee file issues and inspection findings |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 3
Date: Mar 14, 2024
Visit Reason
The inspection was conducted based on complaints regarding failure to obtain a Department of Criminal Investigation (DCI) clearance for a Certified Nursing Assistant, failure to provide bed-hold notice to residents or their representatives upon hospital transfer, and failure to provide appropriate catheter care to a resident.
Complaint Details
The complaint investigation found substantiated deficiencies related to employee background checks, bed-hold notification failures, and catheter care issues.
Findings
The facility failed to obtain a DCI clearance for one CNA, failed to notify residents or their representatives about bed-hold policies and bed holds upon hospital transfers for two residents, and failed to provide appropriate catheter care for one resident, including allowing the urinary drainage bag and tubing to contact the floor and improper cleansing technique.
Deficiencies (3)
Failed to obtain a Department of Criminal Investigation (DCI) report clearing staff to work for 1 of 2 Certified Nursing Assistants (Staff B).
Failed to provide notice to residents or their representatives of the facility's bed-hold policy prior to and upon transfer to the hospital for 2 of 2 residents sampled.
Failed to provide appropriate catheter care when the urinary drainage bag and tubing came into contact with the floor for 1 of 1 residents sampled (Resident #8).
Report Facts
Census: 31
Hours worked: 4.15
Hours worked: 7.3
Hours worked: 7.45
Hours worked: 7.45
Hours worked: 7.45
Hours worked: 7.3
Hours worked: 7.45
White blood cell urine count: 58
Medication dosage: 100
Medication duration: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant | Named in deficiency for lack of DCI clearance and working without proper background check |
| Staff C | Licensed Practical Nurse | Provided interview regarding bed hold process and nursing responsibilities |
| Staff A | Certified Nursing Assistant | Observed improperly handling urinary drainage bag |
| Staff D | Certified Nursing Assistant | Observed performing catheter care improperly |
| Administrator | Provided multiple interviews regarding deficiencies and facility policies | |
| Human Resource Director | Reported issues with employee files and audits | |
| Interim Director of Nursing | IDON | Provided interviews confirming catheter care deficiencies and bed hold policy issues |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 24, 2024
Visit Reason
An investigation of a Facility Self-Reported Incident #118204-I was conducted from January 18, 2024 to January 24, 2024.
Complaint Details
Investigation was related to a facility self-reported incident #118204-I; the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance at the time of the investigation.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 11, 2023
Visit Reason
An on-site revisit of the complaint survey ending on September 7, 2023 was conducted to verify correction of previous deficiencies.
Complaint Details
This visit was a follow-up to a complaint survey ending on September 7, 2023.
Findings
All deficiencies were corrected and the facility was found to be in substantial compliance effective October 5, 2023. The Denial of Payment for New Admits (DPNA) was not effectuated.
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 6
Date: Sep 7, 2023
Visit Reason
Investigation of Complaints #112066-C, #113135-C, #113149-C and Facility Self-Reported Incidents #113234-I and #114119-I conducted from August 29, 2023 to September 7, 2023.
Complaint Details
Complaints #112066-C, #113135-C, and #113149-C were substantiated. Facility Self-Reported Incidents #113234-I and #114119-I were also substantiated.
Findings
The facility was found deficient in multiple areas including failure to notify a physician of a resident's new skin/pressure area, failure to follow resident care plans and physician orders, inadequate assessment and intervention for a resident's significant decline resulting in hospitalization, failure to properly assess and treat a pressure ulcer, and failure to provide adequate supervision leading to a resident fall with hip fracture.
Deficiencies (6)
Failure to notify one resident's physician and/or nurse practitioner related to a new skin/pressure area (Resident #4).
Failure to follow resident care plans for 1 of 3 residents reviewed (Resident #1).
Failure to follow physician's orders for 3 of 3 residents reviewed (Residents #3, #4, and #5).
Failure to provide appropriate assessments and interventions for one resident with decline in ADLs, denial to eat or drink, and apnea resulting in hospitalization (Resident #1).
Failure to appropriately assess and treat an identified pressure ulcer for one resident (Resident #4).
Failure to maintain a safe environment by leaving a resident unattended on the toilet who then fell and sustained a hip fracture (Resident #1).
Report Facts
Resident census: 39
Pressure ulcer measurements: 4
Pressure ulcer measurements: 1
Braden Scale score: 17
BIMS score: 12
BIMS score: 11
Fall risk assessment date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in supervision failure leading to resident fall and hip fracture |
| Staff B | Agency Registered Nurse (RN) | Named in supervision failure leading to resident fall and hip fracture |
| Staff C | Licensed Practical Nurse (LPN) | Named in assessment and care of Resident #4 during decline |
| Staff D | Certified Nursing Assistant (CNA) | Named in care and observation of Resident #4 during decline |
| Staff E | Certified Nursing Assistant (CNA) | Named in care and observation of Resident #4 during decline |
| Staff F | Licensed Practical Nurse (LPN) | Named in care and observation of Resident #4 during decline |
| Staff G | Certified Nursing Assistant (CNA) | Named in care and observation of Resident #4 during decline |
| Director of Nursing | Director of Nursing (DON) | Named in multiple findings including failure to notify physician and supervision failure |
| Nurse Practitioner | Nurse Practitioner (NP) | Named in findings related to notification failures and clinical expectations |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 6
Date: Sep 7, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to notify physicians of resident condition changes, failure to follow care plans, medication administration errors, inadequate assessment and intervention for resident decline, pressure ulcer care deficiencies, and inadequate supervision leading to resident falls.
Complaint Details
The complaint investigation found substantiated failures including delayed physician notification for a resident's pressure ulcer, failure to follow care plans and physician orders, inadequate assessment and intervention for a resident's decline leading to hospitalization, improper pressure ulcer care, and inadequate supervision resulting in a resident fall and hip fracture.
Findings
The facility failed to notify physicians timely about resident condition changes, follow care plans, administer medications as ordered, assess and intervene appropriately for resident decline, provide adequate pressure ulcer care, and maintain adequate supervision to prevent falls. These failures affected multiple residents and resulted in actual harm including a hip fracture and hospitalization.
Deficiencies (6)
Failed to notify one resident's physician related to a new skin/pressure area.
Failed to follow resident care plans for one resident.
Failed to follow physician's orders for medication administration for three residents.
Failed to provide appropriate assessments and interventions for one resident with decline in ADLs, denial to eat or drink, and apnea, resulting in hospitalization.
Failed to appropriately assess and treat an identified pressure ulcer for one resident.
Failed to maintain a safe environment by leaving a resident unattended on the toilet, resulting in a fall and hip fracture.
Report Facts
Resident census: 39
Pressure ulcer measurements: 4
Pressure ulcer measurements: 1
Braden Scale score: 17
BIMS score: 12
BIMS score: 11
Fall risk assessment date: Jun 6, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in fall incident where resident was left unattended on toilet and fell |
| Staff B | Agency Registered Nurse (RN) | Assisted resident after fall and performed assessment |
| Staff C | Licensed Practical Nurse (LPN) | Found resident lethargic and out of it, checked vitals and contacted Physician's Office |
| Staff D | Certified Nursing Assistant (CNA) | Provided care to resident during decline, reported status to nurse |
| Staff E | Certified Nursing Assistant (CNA) | Reported resident confusion and stool changes to nurse |
| Staff F | Licensed Practical Nurse (LPN) | Worked weekend shifts, monitored resident vitals |
| Staff G | Certified Nursing Assistant (CNA) | Cared for resident prior to illness, noted resident was alert and oriented |
| Director of Nursing | Director of Nursing (DON) | Confirmed expectations for physician notification and acknowledged nurse assessment errors |
| Nurse Practitioner | Nurse Practitioner (NP) | Interviewed regarding expectations for notification and care |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 15, 2023
Visit Reason
An on-site revisit of the recertification survey ending January 18, 2023 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective January 19, 2022. The Denial of Payment for New Admits (DPNA) was not effectuated.
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 3
Date: Jan 18, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify a resident's representative of a significant condition change and failure to provide appropriate pressure ulcer care for Resident #89.
Complaint Details
The complaint investigation revealed failure to notify the resident representative of a necrotic wound and failure to provide appropriate pressure ulcer care, resulting in actual harm to Resident #89. The wound was discovered late, and the facility lacked proper policies and documentation.
Findings
The facility failed to notify one out of four resident representatives of a condition change for Resident #89 and failed to assess and implement interventions to prevent the development of a necrotic pressure ulcer related to a cast. The wound was not properly documented or communicated to the resident's representative, and the facility lacked a cast care policy.
Deficiencies (3)
Failed to notify resident representative of a condition change for Resident #89.
Failed to assess and implement interventions to prevent development of a necrotic pressure ulcer related to a cast for Resident #89.
Failed to have a cast care policy.
Report Facts
Census: 36
Wound measurement: 5.6
Wound measurement: 2.7
Wound measurement: 0.4
Braden Scale score: 16
Antibiotic dosage: 875
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Reported failure to notify resident representative of wound and described wound care actions |
| Administrator | Administrator/Registered Nurse (RN) | Reported expectations for notification and documentation, confirmed lack of cast care policy, and provided statements about staff education and documentation failures |
| Physician | Provided medical assessment of wound, antibiotic orders, and comments on wound cause and care expectations | |
| Restorative RN | Restorative Registered Nurse | Reported responsibilities for skin checks around braces or casts |
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 3
Date: Jan 18, 2023
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of Complaints #102361-C, and Facility Self-Reported Incidents #102362-I and #110313-I.
Complaint Details
Complaint #102361-C was substantiated. Facility Self-Reported Incidents #102362-I and #110313-I were substantiated.
Findings
The facility was found deficient in notifying resident representatives of condition changes and in preventing and treating pressure ulcers, specifically for Resident #89. The facility failed to notify the resident representative of a necrotic wound and failed to implement a cast care policy. The facility also failed to assess and implement interventions to prevent pressure ulcers related to a cast worn by Resident #89.
Deficiencies (3)
Failure to notify resident representative of a condition change for Resident #89.
Failure to assess and implement interventions to prevent pressure ulcers related to a cast worn by Resident #89.
Failure to have a cast care policy and failure to document notification of resident representative regarding wound.
Report Facts
Resident census: 36
Wound measurement: 5.6
Wound measurement: 2.7
Wound measurement: 0.4
Braden Scale score: 16
Antibiotic dosage: 875
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Reported failure to notify resident representative of wound and reported wound to Director of Nursing and Physician. |
| Staff A | Licensed Practical Nurse (LPN) | Reported assisting CNA with Resident #89 and noted foul odor from wound. |
| Administrator | Administrator/Registered Nurse (RN) | Confirmed failure to document notification of resident representative and failure to locate Bath Skin Records. |
| Director of Nursing | Director of Nursing | Provided re-education to nurses on notification and skin integrity policies; responsible for monitoring compliance. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 21, 2021
Visit Reason
The inspection was conducted related to the investigation of Facility Self-Reported Incident #99543.
Complaint Details
Investigation of Facility Self-Reported Incident #99543; the incident was not substantiated.
Findings
The incident investigated was not substantiated according to the report.
Inspection Report
Recertification
Census: 33
Deficiencies: 3
Date: Sep 16, 2021
Visit Reason
The inspection was conducted as part of the facility's recertification survey and investigation of a facility self-reported incident and multiple complaints.
Complaint Details
Complaint #99484 was substantiated following investigation of multiple complaints and a self-reported incident.
Findings
The facility was found deficient in providing required Medicaid/Medicare notices, proper insulin pen administration, and quality assessment and assurance committee documentation. The complaint #99484 was substantiated.
Deficiencies (3)
Failure to provide required Medicaid/Medicare coverage/liability notice to residents.
Failure to properly prime the insulin pen before administration to a resident.
Failure to maintain a quality assessment and assurance committee and documentation of meetings.
Report Facts
Census: 33
Deficiencies cited: 3
QAPI meetings: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lena Garcia | Executive Director | Signed the plan of correction and mentioned as Director of Nursing in findings. |
| Staff A | Registered Nurse Consultant | Reported inability to locate completed CMS forms for Resident #9. |
| Staff B | Registered Nurse | Observed during insulin pen administration and failed to prime the insulin pen. |
| Director of Nursing | Reviewed Insulin Pen Skills checklist and reported expectations for insulin pen priming. | |
| Administrator | Reported findings related to QAPI meetings and expectations. |
Inspection Report
Abbreviated Survey
Census: 31
Deficiencies: 0
Date: Dec 17, 2020
Visit Reason
A Focused COVID-19 Infection Survey Control was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 31
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 24, 2020
Visit Reason
A focused COVID-19 infection control survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 8, 2020
Visit Reason
An investigation of Complaint #90665 was completed at the facility.
Complaint Details
Complaint #90665 was investigated and found not substantiated.
Findings
The complaint was investigated and found to be not substantiated.
Inspection Report
Abbreviated Survey
Census: 37
Deficiencies: 0
Date: Jun 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 37
Inspection Report
Renewal
Census: 38
Deficiencies: 2
Date: Feb 13, 2020
Visit Reason
The inspection was a recertification survey conducted from 2/10/2020 to 2/13/2020 to assess compliance with federal regulations for the facility.
Findings
The facility failed to meet professional standards in the administration of insulin pens and inhalers for certain residents and failed to maintain a sanitary environment in kitchenettes. Corrective actions and staff education were planned and monitored.
Deficiencies (2)
Failure to implement professional standards in insulin pen use and inhaler administration for residents.
Failure to provide a sanitary environment in kitchenettes and LTC kitchen.
Report Facts
Deficiencies cited: 2
Resident census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in insulin pen and inhaler administration deficiencies. |
| Staff B | Licensed Practical Nurse (LPN) | Interviewed regarding insulin pen priming procedures. |
| Staff C | Licensed Practical Nurse (LPN) | Interviewed regarding insulin pen priming procedures. |
| Staff D | Licensed Practical Nurse (LPN) | Interviewed regarding insulin pen priming procedures. |
| Staff E | Front House Lead | Interviewed regarding cleaning schedules for kitchenettes. |
| Culinary Manager | Responsible for monitoring cleaning lists weekly. | |
| Director of Nursing | DON | Responsible for monitoring medication pass compliance. |
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