Inspection Reports for The Views of Cedar Rapids | RidgeView Assisted Living

The inspection was conducted as part of the investigation of Complaint #121431-C and the recertification visit to determine compliance with certification of an Assisted Living Program.

The program failed to follow dietary sanitation policies and medication management policies, including improper labeling and administration of insulin. Additionally, evaluations and service plans were not completed within required timeframes for some tenants, and nurse reviews were not conducted following significant changes in tenant health status.

The visit was complaint-related, investigating Complaint #121431-C. The complaint involved issues with dietary sanitation and medication management policies.

Investigation into Complaint #111245-C at Ridgeview Assisted Living.

No regulatory insufficiencies were cited during the complaint investigation.

Investigation into Complaint #111245-C found no regulatory insufficiencies.

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

The program failed to complete background checks prior to hire for 2 of 7 employees reviewed. Specifically, background checks for Staff D and Staff G were completed after their hire dates.

Recertification visit conducted to determine compliance with certification for an Assisted Living Program and the onsite infection control survey.

No regulatory insufficiencies were cited during the recertification visit or the onsite infection control survey.

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

The program failed to meet staffing requirements as the newly hired Registered Nurse did not ensure that certified and noncertified staff were sufficiently trained within 60 days of employment. Specifically, 2 of 4 staff reviewed were not properly trained or documented within the required timeframe.

The inspection was conducted to investigate complaints #64403-C, #65568-C, #65583-C, and #65585-C regarding regulatory insufficiencies at Rosebush Gardens Assisted Living.

The investigation identified deficiencies in staffing training documentation, nurse delegation procedures, medication administration, and service plans. Specific issues included lack of documented training on Bipap machines for staff, failure to provide services according to training, improper medication administration practices, and service plans not reflecting tenants' identified needs.

Complaints #64403-C, #65568-C, #65583-C, and #65585-C were investigated during this visit.

The inspection was conducted as a Final Recertification Monitoring Evaluation and Complaint/Incident Investigation following a survey by the Department of Inspections and Appeals on April 12 & 13, 2016, triggered by complaint #58207-C and incident #59419-I.

The investigation found that allegations related to tenant rights, service plans, and structure/life safety were not substantiated. However, regulatory insufficiencies were identified in the areas of written occupancy agreements and food service, requiring a Plan of Correction.

The complaint involved allegations that service plans were not reviewed or signed by tenants, and that staff smoked near the building causing smoke to drift inside. All allegations were found not substantiated after interviews and file reviews.

The visit was a Final Recertification Monitoring Evaluation conducted by the Department of Inspections and Appeals in accordance with Iowa Administrative Code chapters 481-67 and 481-69 to evaluate compliance and recertification of the Assisted Living Program at Rosebush Gardens.

No regulatory insufficiencies were found during this evaluation. The program met all requirements, and tenant satisfaction was positive with no deficiencies noted during the on-site investigation.

The inspection was conducted as a final complaint/incident investigation based on complaints regarding tenant deaths, tenant checks, short temper of the manager, and roof leaks with mold in the attic.

The investigation found regulatory insufficiencies related to policies and procedures for tenant death reporting, evaluation and service plans not updated as needed, medication administration issues, tenant rights concerns, and structural damage from a storm with failure to notify the department. Several tenant deaths were reviewed with findings of incomplete incident reports and safety checks.

Complaint/Incident Intake #43880-C involved concerns about tenant deaths and tenant checks. Complaint/Incident Intake #44124-C alleged the manager was short tempered and that the roof had leaked for years causing mold in the attic. The complaints were investigated with findings of regulatory insufficiencies but no substantiation status explicitly stated.

The visit was conducted as a Final Recertification Monitoring Evaluation for Rosebush Gardens Assisted Living Program to review the Plan of Correction and ensure compliance with Iowa Code and Administrative Code requirements.

The report found that the Plan of Correction was accepted and the recertification documents were approved. The program did not receive any regulatory insufficiencies during this certification period. Tenant satisfaction was positive, and some minor food service training deficiencies were noted but addressed.

A complaint investigation was conducted at Rosebush Gardens on April 21, 22, 27 & 28, 2010, to investigate allegations including falsified assessments, inappropriate tenant care, service plan falsifications, medication administration issues, staff training deficiencies, and administrative staff misconduct.

The investigation found no evidence of falsified records or service plans, but identified regulatory insufficiencies related to tenant evaluations, service plan updates, nurse reviews, medication administration documentation, staff training, and administrative practices. Several complaints were unsubstantiated, and no retaliation towards tenants was found. A $1,500 civil penalty was assessed.

The complaint investigation addressed allegations of falsified assessments, inappropriate tenant care including wandering and incontinence, service plan falsifications, medication administration delays, staff training deficiencies, call light malfunctions, leaking windows, snow removal issues, mail mishandling, staff selling prescription drugs, tenant money missing, and intimidation by administrative staff. Most allegations were unsubstantiated or not supported by evidence. No retaliation towards tenants was found.

The inspection was conducted as a complaint investigation and recertification monitoring evaluation at Rosebush Gardens, Burlington, IA, triggered by a complaint regarding the program's driveway and parking lot conditions.

The investigation found no substantiated regulatory insufficiencies. The parking lot and sidewalks were generally clear of snow and ice with minimal residual snow. A fall incident involving Tenant #1 was reported and investigated, but no regulatory insufficiencies were noted. Staff training deficiencies were identified but not classified as regulatory insufficiencies.

The complaint alleged that the program's driveway and parking lot contained packed snow and ice, causing difficulty walking. The investigation found the parking lot and sidewalks were mostly clear with minimal snow. A fall incident on 12-11-09 involving Tenant #1 was reported, resulting in a left ankle fracture/dislocation. The program reported the incident to the Department. No regulatory insufficiencies were substantiated related to the complaint.

The visit was a recertification monitoring evaluation conducted to review the facility's compliance with regulatory requirements and the Plan of Correction submitted in response to identified regulatory insufficiencies.

The evaluation found multiple regulatory insufficiencies related to the program's failure to consistently evaluate tenants' functional, cognitive, and health status prior to and within 30 days of occupancy, and deficiencies in individualized service plan development. There were no substantiated regulatory insufficiencies during this certification period starting March 26, 2008.

A complaint investigation on-site visit was conducted at Rosebush Gardens to investigate multiple allegations including improper notification of room rate increases, tenant care concerns, destruction of records, and staffing issues.

The investigation found no regulatory insufficiencies for most allegations, except for deficiencies related to service plans not being consistently developed or updated within 30 days of occupancy or with changes in condition, and physician orders not documented with time, date, and signature. All other complaints were unsubstantiated.

The complaint investigation was triggered by allegations including improper notification of room rate increases, tenant exceeding level of care, destruction of records, inaccurate service plans, medication order transcription errors, unauthorized menu changes, failure to provide special diets, missed meals due to lack of assistance, staff dishonesty, inadequate staffing, improper handling of colostomy care, forced showers, lying to tenants, and unsafe facility conditions. Most allegations were found unsubstantiated except for service plan and physician order documentation deficiencies.

A complaint investigation on-site visit was conducted at Rosebush Gardens Assisted Living to investigate allegations regarding tenant care and facility conditions.

The investigation found regulatory insufficiencies in the program's consistent evaluation of tenant cognitive and functional abilities, updating of service plans, and assessment and documentation of tenant health status. No deficiencies were noted regarding the building's ceiling damage or tenant exclusion criteria.

The complaint alleged that Tenant #1 required total care and could not get out of bed or assist with toileting, that the service plan was not reflective of current needs, and that the building’s lounge ceiling was falling down and leaking without repair. The investigation found some allegations unsubstantiated and noted regulatory insufficiencies related to tenant evaluation and service planning.

An on-site monitoring evaluation was conducted at Rosebush Gardens Assisted Living to assess compliance with assisted living program regulations and to evaluate tenant care and services.

The evaluation identified multiple regulatory insufficiencies including inconsistent completion of tenant evaluations prior to occupancy, inadequate individualized service plans that do not address current tenant needs or behaviors, failure to follow acceptable medication protocols, incomplete 90-day medication reviews, and insufficient staff training for delegated nursing tasks.

There were substantiated complaints in the area of medications during this certification period.

A complaint investigation on-site visit was conducted at Rosebush Gardens to investigate allegations related to the inability to account for tenants' narcotic medications.

The investigation found that the program did not count narcotic medications according to accepted medication protocol, did not appropriately delegate medication administration to a specific staff member, and could not account for missing narcotics. Significant medication discrepancies and potential narcotic theft were identified involving Staff Member #1.

The complaint was related to allegations that staff at the program could not account for tenants’ narcotic medications. The complaint was investigated and substantiated with findings of medication errors and missing narcotics.