The Gardens of Cedar Rapids

Inspectors wroteBased on observation, clinical record review, staff interview and facility policy review the facility failed to accurately account for controlled/narcotic medications for 3 of the 3 residents reviewed (Residents #89, #90, and #92). The facility reported a census of 35 residents.

Inspectors wroteBased on clinical record review, staff interviews, observations, and facility policy review the facility failed to prevent drug diversion for 3 of 3 resident's controlled/narcotic medications (Resident#89, #90, #92). The facility reported a census of 35 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review the facility failed to implement Abuse Prevention policies for an investigation into reported misappropriated resident medications for 2 out of 3 residents reviewed (Residents #89 and #90). The facility reported a censes of 35 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review the facility failed to report misappropriation of 2 out of 3 resident's medications (Resident #89, and #90) to the State Agency (SA) and law enforcement. The facility reported a census of 35 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review the facility failed to investigate a reported incident of misappropriated resident medications for 2 of 3 residents reviewed (Resident#89, and 90) and failed to prevent further misappropriation of medication of 1 resident (Resident #92). The facility reported a census 35 residents.

Inspectors wroteBased on observations, staff interviews, and facility policy review the facility failed to securely store medication 2 out of 2 times on 1 out of 2 medication carts on 1 out of 4 days observed. The facility reported a census of 35 residents.

Inspectors wroteBased on clinical record review, policy review, Center for Disease Control and Prevention (CDC) 2025 Adult Immunization Schedule, and staff interview the facility failed to offer pneumococcal vaccinations according to the CDC for 1 of 5 residents reviewed (Resident #4). The facility identified a census of 35 residents.

Inspectors wroteBased on observation, clinical record review, and staff interview, the facility failed to provide interventions/treatments for 1 of 3 residents with skin breakdown (Resident #3) and the facility failed to obtain physician's orders for 1 of 3 residents reviewed (Resident #3). The facility identified a census of 36 residents.

Inspectors wroteBased on employee file review, policy review and staff interview, the facility failed to obtain a Department of Criminal Investigation (DCI) report clearing staff to work for 1 of 2 Certified Nursing Assistants (CNA) reviewed (Staff B). The facility reported a census of 31 residents.

Inspectors wroteBased on clinical record review, staff interview, and facility admission agreement, the facility failed to provide notice to the resident and/or the legal representative of the facility's bed-hold policy prior to and upon transfer to the hospital for 2 of 2 residents sampled (Resident #2 and #10). The facility identified a census of 31 residents.

Inspectors wroteBased on observation, clinical record review, policy reiew and staff interview, the facility 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). The facility identified a census of 31 residents.

Inspectors wroteBased on clinical record review, staff, family, and Nurse Practitioner (NP) interviews, the facility failed to assure that staff provided appropriate assessments and interventions for one (1) resident who presented with a decline in activities of daily living (ADL's), denial to eat or drink, and a period of apnea (absence of breathing) (Resident #1). This failure resulted the resident in a significant change of condition and sent to the emergency room (ER) for treatment. The facility identified a census of 39 residents. Findings Include: A Minimum Data Set (MDS) Assessment form dated 5-2-23 indicated Resident #4 had diagnoses that included anemia, diabetes mellitus (DM), a displaced fracture of her left humerus, reduced mobility, rhabdomylosis (breakdown of muscle tissue that releases protein into the blood). [...]

Inspectors wroteBased on clinical record review, staff interviews, resident rights and facility policy review, the facility failed to appropriately assess and treat an identified pressure ulcer for one (1) resident reviewed for pressure ulcers (Resident #4). The facility identified a census of 39 residents. Findings Include: The MDS (Minimum Data Set) Assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. [...]

Inspectors wroteBased on clinical record review, staff and Nurse Practitioner (NP) interviews the facility failed to maintain a safe and secure environment by leaving a resident alone on the toilet, who then fell and sustained a hip fracture for 1 of 3 residents reviewed for supervision (Resident #1). The facility identified a census of 39 residents. Findings Include: A Minimum Data Set (MDS) Assessment form dated 6-15-23 indicated Resident #1 with diagnoses that included cancer, orthostatic hypotension, Parkinson's disease, adult failure to thrive, malaise and atrial fibrillation (AF). The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 (moderately impaired cognitive status), required extensive assistance of staff with dressing and personal hygiene, limited assistance of staff with transfers, ambulation and toilet use. [...]

Inspectors wroteBased on clinical record review, staff interview, Nurse Practitioner (NP) interview and facility policy review, the facility failed to notify one (1) resident's Physician and/or Nurse Practitioner (NP) related to a new skin/pressure area (Resident #4). The facility identified a census of 39 residents. Findings Include: A Minimum Data Set (MDS) Assessment Form dated 5-2-23 indicated Resident #4 had diagnoses that included anemia, diabetes mellitus (DM), a displaced fracture of her left humerus, reduced mobility, rhabdomylosis (breakdown of muscle tissue that releases protein into the blood). [...]

Inspectors wroteBased on clinical record review and staff interview, the facility staff failed to follow resident Care Plans for 1 of 3 residents reviewed (Resident #1). The facility identified a census of 39 residents. Findings Include: A Minimum Data Set (MDS) Assessment form dated 6-15-23 indicated Resident #1 had diagnoses that included cancer, orthostatic hypotension, Parkinson's disease, adult failure to thrive, malaise and atrial fibrillation (AF). The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 (moderately impaired cognitive status), required extensive assistance of staff with dressing and personal hygiene, limited assistance of staff with transfers, ambulation and toilet use. A Care Plan with a Focus area initiated 10-31-22 indicated the resident as at risk for falling related to (R/T) Parkinson's disease. [...]

Inspectors wroteBased on clinical record review, staff interview and facility policy review, the facility failed to follow Physician's Orders for 3 of 3 residents reviewed (Residents #3, #4 and #5). The facility identified a census of 39 residents. Findings Include: 1. Review of a Medication Administration Audit Report form for Resident #3 dated 8-30-23 at 2:54 p.m. revealed the following Physician Orders and actual administration times of the following medications: a. On 10-6-22: Levothyroxine 75 micrograms (mcg) one (1) tablet by mouth (po) for low thyroid levels, Losartan Potassium oral tablet 25 milligrams (mg) 1 tablet po one time a day (QD) for high blood pressure - all scheduled at 7 a.m. and administered at 10:17 a.m. 2. Review of a Medication Administration Audit Report form for Resident #4 dated 8-30-23 at 2:52 p.m. [...]