Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 21, 2025
Visit Reason
A complaint investigation for facility reported incident #2642387 was conducted.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint investigation for incident #2642387; facility found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
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
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.
Severity Breakdown
SS=D: 4
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to prevent misappropriation of resident medications and failure to implement abuse prevention policies. | SS=D |
| Failure to report alleged violations timely and thoroughly investigate abuse, neglect, exploitation, and misappropriation. | SS=D |
| Failure to accurately account for controlled/narcotic medications and reconcile discrepancies. | SS=E |
| Failure to label and store drugs and biologicals properly under secure conditions. | SS=D |
| Failure to provide influenza and pneumococcal immunizations according to CDC guidelines. | SS=D |
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
Plan of Correction
Deficiencies: 0
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
Complaint Investigation
Census: 36
Deficiencies: 1
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.
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.
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.
Severity Breakdown
Severity Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide interventions/treatments for 1 of 3 residents with skin breakdown and failure to obtain physician's orders for that resident. | Severity Level D |
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
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
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.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to develop and implement written policies and procedures to prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. | SS=D |
| 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. | SS=D |
| Failure to provide appropriate catheter care when urinary drainage bag and tubing contacted the floor, risking infection for 1 of 1 residents sampled. | SS=D |
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
Deficiencies: 0
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.
Findings
The facility was found to be in substantial compliance at the time of the investigation.
Complaint Details
Investigation was related to a facility self-reported incident #118204-I; the facility was found to be in substantial compliance.
Inspection Report
Follow-Up
Deficiencies: 0
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.
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.
Complaint Details
This visit was a follow-up to a complaint survey ending on September 7, 2023.
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 6
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.
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.
Complaint Details
Complaints #112066-C, #113135-C, and #113149-C were substantiated. Facility Self-Reported Incidents #113234-I and #114119-I were also substantiated.
Severity Breakdown
SS=D: 3
SS=G: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to notify one resident's physician and/or nurse practitioner related to a new skin/pressure area (Resident #4). | SS=D |
| Failure to follow resident care plans for 1 of 3 residents reviewed (Resident #1). | SS=D |
| Failure to follow physician's orders for 3 of 3 residents reviewed (Residents #3, #4, and #5). | SS=D |
| 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). | SS=G |
| Failure to appropriately assess and treat an identified pressure ulcer for one resident (Resident #4). | SS=G |
| Failure to maintain a safe environment by leaving a resident unattended on the toilet who then fell and sustained a hip fracture (Resident #1). | SS=G |
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
Re-Inspection
Deficiencies: 0
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
Annual Inspection
Census: 36
Deficiencies: 3
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.
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.
Complaint Details
Complaint #102361-C was substantiated. Facility Self-Reported Incidents #102362-I and #110313-I were substantiated.
Deficiencies (3)
| Description |
|---|
| 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
Sep 21, 2021
Visit Reason
The inspection was conducted related to the investigation of Facility Self-Reported Incident #99543.
Findings
The incident investigated was not substantiated according to the report.
Complaint Details
Investigation of Facility Self-Reported Incident #99543; the incident was not substantiated.
Inspection Report
Recertification
Census: 33
Deficiencies: 3
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.
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.
Complaint Details
Complaint #99484 was substantiated following investigation of multiple complaints and a self-reported incident.
Severity Breakdown
Level B: 1
Level D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide required Medicaid/Medicare coverage/liability notice to residents. | — |
| Failure to properly prime the insulin pen before administration to a resident. | Level D |
| Failure to maintain a quality assessment and assurance committee and documentation of meetings. | Level B |
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
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
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
Oct 8, 2020
Visit Reason
An investigation of Complaint #90665 was completed at the facility.
Findings
The complaint was investigated and found to be not substantiated.
Complaint Details
Complaint #90665 was investigated and found not substantiated.
Inspection Report
Abbreviated Survey
Census: 37
Deficiencies: 0
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
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.
Severity Breakdown
Level 3: 1
Level 4: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to implement professional standards in insulin pen use and inhaler administration for residents. | Level 3 |
| Failure to provide a sanitary environment in kitchenettes and LTC kitchen. | Level 4 |
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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