Inspection Reports for The Keystones of Cedar Rapids

The recertification visit was conducted to determine compliance with certification of a Dedicated Dementia Specific Assisted Living Program.

The program failed to complete evaluations as needed with significant change for tenants, specifically related to wound care and service plans. Several tenants' service plans did not reflect current treatments or risks, and evaluations were not updated as required.

The inspection was conducted following investigation of Incident #112364-I involving an elopement of Tenant #1 at Keystone Cedars Memory Care.

The program failed to follow its policies and procedures related to missing persons and door alarms, resulting in an elopement incident. Additionally, the service plan for Tenant #1 did not reflect specific safety needs or updated interventions after multiple elopements. Door alarms were malfunctioning or not responded to timely, and staff failed to notify leadership promptly.

The complaint investigation was triggered by Incident #112364-I involving Tenant #1's elopement on 4/16/23. The investigation found the program did not respond properly to door alarms, delayed notification to leadership, and inadequate safety checks. The complaint was substantiated based on these findings.

The inspection was conducted as a recertification visit to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program and to investigate Complaint #102204-C and Incident #102301-I.

The program failed to follow its policies and procedures related to incident reports and responding to door alarms, failed to treat a tenant with dignity and respect, failed to provide services according to training, failed to complete evaluations and nurse reviews as needed, failed to develop and update service plans based on evaluations, and failed to ensure staff completed required dementia-specific training within 30 days of hire.

Complaint #102204-C and Incident #102301-I were investigated related to incidents involving Tenant #1 elopements and staff conduct.

The recertification visit was conducted to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.

The program failed to ensure staff employment background checks were completed within 30 days of hire, resulting in a regulatory insufficiency related to background check validity.

Investigation of incident #77620-I at Keystone Cedars Assisted Living Program for People with Dementia.

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

Investigation of incident #77620-I resulted in no regulatory insufficiencies cited.

Recertification visit conducted to determine compliance with certification for an Assisted Living Program.

There were no regulatory insufficiencies cited during the recertification visit.

The inspection was conducted as a complaint/incident investigation related to Incident #58234-I, focusing on regulatory insufficiency in the area of Life Safety.

The investigation found that the facility failed to have an operating door alarm on each exit door in the dementia-specific program, resulting in a tenant leaving the building without the alarm sounding. The tenant was safely returned, and the alarm system was in the process of being converted to an audible alarm. Staff interviews and documentation confirmed the deficiency.

The complaint investigation was substantiated with a regulatory insufficiency identified related to Incident #58234-I involving a tenant eloping from the dementia unit without the door alarm sounding.

The inspection was conducted as a complaint/incident investigation related to staffing and a reported fall with injury at Keystone Cedars Assisted Living Program.

No regulatory insufficiencies were found during the investigation based on review of tenant files, incident reports, program policy, and staff interviews.

The complaint involved staffing and an incident of a fall with injury. The investigation found no insufficiencies.

The visit was conducted as a Final Recertification Monitoring Evaluation to assess compliance with Iowa Code chapter 231C and Iowa Administrative Code chapters 481-67 and 481-69, focusing on criminal, dependent adult abuse, and child abuse record checks.

The report found regulatory insufficiencies related to failure to conduct required criminal history and abuse record checks for staff prior to employment, as evidenced by missing or misfiled documentation for two staff members.

The inspection was conducted as a complaint/incident investigation following a report that a tenant eloped from the assisted living program.

The investigation found that Tenant #1 eloped but was found safe and returned to the facility without injury. There were no regulatory insufficiencies identified related to the incident, though documentation of hourly checks was inconsistent.

The complaint involved a tenant eloping from the program. The investigation found no regulatory insufficiencies and no history of prior elopements for Tenant #1. Staff and family were involved in monitoring and responding to the incident.

The inspection was conducted as a complaint/incident investigation regarding regulatory insufficiencies related to criteria for admission and retention, evaluation, service plans, tenant rights, and nurse review at Keystone Cedars Assisted Living.

The report found that the facility retained a tenant who exceeded retention criteria and was physically and sexually abusive to staff and another tenant. Multiple regulatory insufficiencies were cited, including failure to protect tenants, inadequate service plans, and violations of tenant rights.

Complaint Intake #43989-C involved allegations that the facility retained a tenant who was physically and sexually abusive to staff and another tenant, failed to notify a tenant's Durable Power of Attorney after a fall, and had questionable evaluations and service plans. The complaint was substantiated with findings of regulatory insufficiencies.

The inspection was conducted as a complaint/incident investigation based on allegations including unauthorized posting of tenant pictures on social media, presence of animals in the program, tenants being given wrong medications, insufficient staffing during nighttime hours, and tenants requiring nursing home level of care.

The investigation found no regulatory insufficiencies related to medications or criteria for admission and retention. There was a regulatory insufficiency related to staffing due to lack of documentation of medication administration training for some staff and insufficient trained staff to meet tenant needs. Tenant rights were generally respected with signed consents for social media postings and no evidence of unauthorized animal interactions or forced gift giving.

The complaint investigation was substantiated with findings related to staffing and training deficiencies. Other allegations such as medication errors and tenant rights violations were not substantiated.

The inspection was conducted as a complaint/incident investigation following a report that a tenant exited the dementia unit unsupervised and triggered a door alarm.

The investigation found that Tenant #1 exited the building but was safely located and returned without injury. Staff followed policies regarding monitoring and response. No regulatory insufficiencies were identified.

The complaint involved a tenant who exited the dementia unit and triggered an alarm. The tenant was found outside near a locked exit door and was safely escorted back. Staff followed procedures, and no injuries occurred. The tenant was identified as an elopement risk and had a service plan with interventions to prevent exit seeking behaviors. The complaint was not substantiated as no regulatory insufficiencies were found.

The inspection was conducted as a final complaint/incident investigation regarding regulatory insufficiencies related to policies and procedures, program reporting to the department, and life safety at Keystone Cedars Assisted Living following a tenant elopement incident.

The program failed to comply with regulatory requirements, resulting in a $500 civil penalty due to imminent danger or substantial probability of death or physical harm to a tenant who eloped through a deactivated exit door alarm. The program did not report the elopement and did not complete an incident report. The south exit door alarm was found deactivated, and staff were unaware of this. Additional regulatory insufficiencies were noted in incident reporting and alarm system procedures.

Complaint investigation was substantiated. The tenant eloped from the dementia unit through a deactivated south exit door alarm. The program failed to report the elopement and did not complete an incident report. The door alarm was found deactivated and staff were unaware. The investigation confirmed regulatory insufficiencies in policies, reporting, and life safety.

The visit was a Final Recertification Monitoring Evaluation to review recertification documents and conduct an on-site monitoring evaluation of Keystone Cedars Assisted Living in Cedar Rapids, IA.

No regulatory insufficiencies were found during the evaluation. Tenant satisfaction was positive, with clean and safe conditions, timely nursing services, and adequate activities offered.

The inspection was conducted as a complaint investigation following an allegation that the program failed to provide proper care and follow-up after an incident with injury.

The investigation reviewed tenant incidents involving falls and injuries, staff responses, and documentation. No regulatory insufficiencies were identified during the investigation.

Complaint Allegation: It was alleged the Program failed to provide proper care and follow-up after an incident with injury. The investigation included review of three tenant incidents involving falls and injuries, staff actions, and documentation. No regulatory insufficiencies were found.

The visit was a final recertification monitoring evaluation conducted to review the assisted living program's compliance with Iowa Code and Administrative Code requirements.

No regulatory insufficiencies were found during this onsite recertification monitoring evaluation. Previous complaint and incident investigations had resulted in regulatory insufficiencies and civil money penalties.

A complaint investigation completed on February 3 and 4, 2010 resulted in regulatory insufficiencies in the areas of Evaluation of Tenant, Service Plans and Other, with a civil penalty of $2,000 assessed.

A complaint investigation was conducted at Keystone Cedars Assisted Living on February 3 and 4, 2010, triggered by allegations related to tenant care, service plans, and other regulatory concerns.

The investigation found regulatory insufficiencies in evaluation of tenants, service plans, and other areas. A tenant was found outside without appropriate clothing and sustained two pubic fractures. The program was assessed a $2,000 civil penalty and the Plan of Correction was accepted but the request for reconsideration was denied.

The complaint investigation was substantiated. It involved a tenant found outside without appropriate winter clothing who fell on ice and sustained two pubic fractures. The tenant had an elopement incident and inadequate staff response was noted.

The visit was conducted as a final incident investigation following a tenant's death due to positional asphyxiation after rolling out of bed and becoming wedged between the mattress and an assistive bed rail.

The investigation found that the program did not develop individualized service plans reflecting tenant needs, specifically regarding bed rail use. Staff responded to the incident but the tenant died from positional asphyxiation. No regulatory insufficiency was noted related to the incident itself, but a $500 civil penalty was assessed for regulatory insufficiencies in service plans.

The complaint involved a tenant who rolled out of bed and died due to positional asphyxiation caused by being wedged between the mattress and an assistive bed rail. Staff found the tenant unresponsive and emergency services were called. The Medical Examiner confirmed the cause of death as positional asphyxiation. The incident was investigated with interviews of staff and review of tenant records.

An on-site monitoring evaluation was conducted at Keystone Cedars Assisted Living on May 28, 2008, to review the Plan of Correction in response to the Recertification Monitoring Evaluation Report and assess compliance with regulatory requirements.

The evaluation found multiple regulatory insufficiencies related to tenant evaluations, service plans, medication administration, nurse review, food service orientation, staffing training, dementia-specific education, and structural maintenance. The program had no regulatory insufficiencies in the past certification period but currently did not consistently meet several regulatory requirements.

A complaint investigation was conducted at Keystone Cedars to address allegations regarding failure to provide an updated occupancy agreement, inadequate tenant evaluations, retention of a tenant requiring a higher level of care, and insufficient staffing to meet tenant needs.

The investigation found multiple regulatory insufficiencies including failure to update and obtain signatures on occupancy agreements after service level changes, inadequate evaluation of tenants' cognitive and functional status after hospitalization or condition changes, retention of a tenant who required a higher level of care and was a danger to self, and insufficiently trained staff to meet the needs of an insulin-dependent diabetic tenant.

The complaint investigation was initiated due to allegations that the program failed to provide an updated occupancy agreement after a tenant's transfer to a higher service level, did not properly evaluate tenants after hospitalization or condition changes, retained a tenant requiring a higher level of care who was a danger to self, and did not provide appropriate staffing and services to meet tenant needs. No substantiated complaints were noted in the certification period prior to this investigation.

An on-site monitoring evaluation was conducted at Keystone Cedars to assess compliance with assisted living program regulations and to evaluate tenant satisfaction and program operations.

The program generally met tenant satisfaction with activities, safety, and food quality. However, a regulatory insufficiency was found regarding transportation services, specifically that the program did not have an appropriately licensed driver for the program's van.