The Gardens Of Cedar Rapids

In the surveyor’s words

From the most serious findings on record at The Gardens Of Cedar Rapids, in the surveyor’s own words.

• Actual harm, isolatedF684Sep 7, 2023

  Based 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. […]

• Actual harm, isolatedF686Sep 7, 2023

  Based 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. […]

• Actual harm, isolatedF689Sep 7, 2023

  Based 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). […]

• Actual harm, isolatedF686Jan 18, 2023

  Based on clinical record review, staff and Physician interviews, and facility policy review the facility failed to assess and implement interventions to prevent the development of a necrotic pressure area related to a cast worn for one out of four residents reviewed (Resident #89). The facility reported a census of 36 residents. Findings Include: The MDS (Minimum Data Set) Assessment identifies the definition of pressure ulcers as follows: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. […]

• No harm, potential for more than minimal, patternF755Jan 9, 2025

  Based 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. Finding include: 1. The Minimum Data Set (MDS) assessment for Resident #89 dated 7/18/24, listed diagnoses of non-Alzheimer's dementia, Parkinson's disease, and seizure disorder. The Brief Interview for Mental Status (BIMS) reflected a score of 1, severe cognitive impairment. The Care Plan for R#89 dated 4/26/24, directed staff to administer medications as ordered. Monitor and record effectiveness. […]