Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Gardens Of Cedar Rapids during CMS and state inspections, most recent first.
The facility failed to accurately account for controlled medications for three residents, leading to discrepancies in Morphine and Ativan records. A resident with dementia and Parkinson's had a missing 2 ml of Morphine, while another with dementia and diabetes had a 2.25 ml discrepancy. A third resident with cancer and arthritis had unaccounted amounts of Morphine and Ativan. The facility's policy requires two nurses to count and document narcotics together, but this process was not followed, resulting in unreported discrepancies.
A resident with severe cognitive loss and multiple health conditions was not offered a pneumococcal vaccination according to CDC guidelines. The DON, responsible for vaccination tracking, had not reviewed the resident's 2018 History and Physical and misunderstood CDC requirements despite recent education. An audit identified 35 residents needing updated vaccinations, but the deficiency for this resident remained unaddressed.
A long-term care facility failed to prevent drug diversion involving controlled medications for three residents. Discrepancies in morphine counts were noted, with missing doses unaccounted for. Staff A, an RN, was observed engaging in suspicious activities, including handling medication boxes and consuming a liquid from a cup. Staff reported her disoriented behavior, but the facility's policy on abuse prevention and misappropriation of property was not followed, leading to the deficiency.
A facility failed to implement its Abuse Prevention policies, resulting in unaccounted morphine for two residents with severe cognitive impairments. Discrepancies in medication records were noted, with missing doses not documented in the MAR. An RN reported the issue to the previous DON, who failed to investigate due to illness, while another RN did not notify management and documented a 'count correction' without proper reconciliation.
A facility failed to report the misappropriation of medications for two residents to the State Agency and law enforcement. One resident had a 2 ml discrepancy in morphine count, while another had a 2.25 ml discrepancy, with no explanations provided. An RN reported the issue to the previous DON, but it was not addressed promptly, violating the facility's policy on abuse prevention and reporting.
A facility failed to investigate and address medication misappropriation for three residents, leading to discrepancies in narcotic counts. A resident with severe cognitive impairment had unaccounted morphine, while another had a morphine discrepancy. A third resident experienced discrepancies in morphine and Ativan counts. Staff A, RN, was involved in these discrepancies, appearing disoriented during shifts. The facility did not follow its abuse prevention policy, compromising resident safety.
The facility failed to securely store medications on a medication cart, which was found unlocked twice in the 200 Wing lounge area. An LPN acknowledged the oversight, and the DON confirmed that carts should be locked at all times, as per facility policy.
A resident with multiple skin breakdowns did not receive necessary interventions and treatments due to the facility's failure to obtain physician orders. Despite having active diagnoses and recommendations for care, the resident's treatment orders were not transcribed onto the MAR/TAR for several days. The DON faxed wound measurements to the physician but did not follow up, resulting in a delay. Interviews revealed that the facility's management expected nurses to obtain orders, but this was not done, leading to the deficiency.
Medication Discrepancies in Controlled Substances
Penalty
Summary
The facility failed to accurately account for controlled and narcotic medications for three residents, leading to discrepancies in medication records. Resident #89, diagnosed with non-Alzheimer's dementia, Parkinson's disease, and seizure disorder, had a discrepancy in the Morphine solution count. The Controlled Substance Count & Usage Record showed a missing 2 ml of Morphine, with no explanation provided for the discrepancy. Additionally, the Medication Administration Record (MAR) lacked documentation of a dose being administered, further complicating the accountability of the medication. Resident #90, with diagnoses including non-Alzheimer's dementia, diabetes mellitus, and heart failure, also experienced a discrepancy in the Morphine count. The Controlled Substance Count & Usage Record indicated a missing 2.25 ml of Morphine, with no explanation for the discrepancy. The MAR did not document a PRN dose administered, contributing to the lack of clarity in medication management. Similarly, Resident #92, diagnosed with lung cancer, non-Alzheimer's dementia, arthritis, and diabetes mellitus, had discrepancies in both Morphine and Ativan solutions. The records failed to account for missing amounts of these medications, with no explanations provided. The facility's policy on controlled substances requires two nurses to count and document narcotic medications together, reporting any discrepancies to the Director of Nursing (DON). However, observations revealed that the process was not followed correctly, as one nurse failed to visually confirm the medication count. The DON confirmed the expectation for accurate counts and immediate reporting of discrepancies, but the facility's practices did not align with these expectations, leading to unaccounted medication discrepancies.
Failure to Offer Pneumococcal Vaccination per CDC Guidelines
Penalty
Summary
The facility failed to offer pneumococcal vaccinations according to the CDC guidelines for one of the five residents reviewed. Resident #4, who had a history of severe cognitive loss, cancer, heart failure, Alzheimer's Dementia, Non-Alzheimer's Dementia, and sleep apnea, was not offered the pneumococcal vaccination. The resident's Minimum Data Set (MDS) assessment indicated that the pneumococcal vaccination had not been offered, despite the resident having received the Pneumococcal 23 (PPSV23) vaccination in 2014. The facility's records showed that the resident was documented as ineligible for the Prevnar 13 (PCV13) vaccination. The Director of Nursing (DON) reported that Resident #4 was considered ineligible for the pneumococcal vaccination based on a 2018 History and Physical, which she had not reviewed. The DON acknowledged that she was responsible for vaccination tracking and had received further education on pneumococcal vaccinations in December 2024. However, she had not fully understood the CDC requirements at that time. An audit conducted by a Nurse Consultant in December 2024 identified 35 residents needing updated pneumococcal vaccinations, but the deficiency for Resident #4 remained unaddressed. The facility's Immunization Policy required all new residents to receive a pneumococcal immunization unless contraindicated, previously immunized, or refused by the resident or representative.
Failure to Prevent Drug Diversion in LTC Facility
Penalty
Summary
The facility failed to prevent drug diversion involving controlled/narcotic medications for three residents. Resident #89, diagnosed with non-Alzheimer's dementia, Parkinson's disease, and seizure disorder, had a discrepancy in the morphine count on 9/13/24. The Controlled Substance Count & Usage Record showed 24 ml of morphine at 2:00 PM, but only 22 ml remained at 10 PM, with no record of administration for the missing 2 ml. Similarly, Resident #90, with severe cognitive impairments, had a morphine count discrepancy on the same date. The record showed 8.75 ml at 2 PM, but only 6 ml remained at 10 PM, with no explanation for the missing 2.25 ml. Resident #92, with intact cognition, had a discrepancy in the morphine count on 9/19/24, where 0.25 ml was unaccounted for. Staff interviews and video surveillance revealed that Staff A, an RN, was involved in suspicious activities related to the medication discrepancies. Staff D, an RN, reported that Staff A took a long time to complete documentation and failed to reconcile doses on the Medication Administration Record (MAR). Staff D also noted that Staff A appeared disoriented and had glazed eyes. Video footage showed Staff A removing boxes from the medication room, placing them in a pink bag, and later appearing to add drops from a bottle into a hot pink cup, which she drank from. Staff A's behavior raised concerns among other staff members, who noted her staggering, slurred speech, and glassy eyes. The facility's policy on abuse prevention and misappropriation of resident property was not adhered to, as evidenced by the failure to prevent the diversion of medications. Staff A's actions, including the unauthorized handling and potential consumption of controlled substances, were not reported promptly to the Director of Nursing (DON) or other management. The facility's lack of immediate response to the discrepancies and the failure to follow proper procedures for narcotic counts contributed to the deficiency. The DON was not informed of the incidents until after they occurred, and the pharmacy later reported missing oxycodone tablets from the emergency drug kit.
Failure to Implement Abuse Prevention Policies Leads to Medication Misappropriation
Penalty
Summary
The facility failed to implement its Abuse Prevention policies effectively, leading to an investigation into the misappropriation of resident medications for two residents. Resident #89, who had severe cognitive impairment due to non-Alzheimer's dementia, Parkinson's disease, and a seizure disorder, had discrepancies in the Controlled Substance Count & Usage Record. On a specific date, the record showed a missing 2 ml of Morphine that was not accounted for in the Medication Administration Record (MAR), which lacked documentation of the dose being administered. Similarly, Resident #90, also with severe cognitive impairments, had a discrepancy in the morphine count, with 2.25 ml unaccounted for. The MAR did not reflect any PRN doses being signed out on the day in question. Staff interviews revealed that Staff D, an RN, noticed the discrepancies during a shift change and reported them to the previous Director of Nursing (DON), Staff B. However, Staff A, another RN, failed to notify the DON or nurse manager about the discrepancies and instead documented a 'count correction' without reconciling the doses on the MAR. Staff D expressed concerns about Staff A's behavior and the lack of proper documentation and notification. Staff B, the previous DON, admitted to receiving a text about the issue but failed to investigate further due to personal illness, leading to a delay in addressing the incident.
Failure to Report Medication Misappropriation
Penalty
Summary
The facility failed to report the misappropriation of medications for two residents to the State Agency and law enforcement. Resident #89, diagnosed with non-Alzheimer's dementia, Parkinson's disease, and seizure disorder, had a discrepancy in the morphine count on 9/13/24. The Controlled Substance Count & Usage Record showed a missing 2 ml of morphine, with no explanation provided. The Medication Administration Record (MAR) lacked documentation of the administered dose, indicating a failure in proper medication management and reporting. Similarly, Resident #90, with severe cognitive impairments and diagnoses including non-Alzheimer's dementia, diabetes mellitus, and heart failure, experienced a discrepancy in the morphine count. The Controlled Substance Count & Usage Record indicated a missing 2.25 ml of morphine, with no explanation for the discrepancy. Staff D, an RN, reported the issue to the previous Director of Nursing (DON) but the concern was not addressed promptly, leading to a failure in reporting the misappropriation. The facility's policy on abuse prevention and reporting requires immediate reporting of such incidents to the charge nurse and subsequently to the Administrator or designated representative. However, the previous DON failed to report the narcotic discrepancies to the Administrator for further investigation and reporting. This oversight resulted in a breach of the facility's policy and regulatory requirements for timely reporting of misappropriation of resident property.
Failure to Investigate Medication Misappropriation
Penalty
Summary
The facility failed to investigate and address incidents of misappropriated medications for three residents, leading to discrepancies in narcotic counts and potential misuse. Resident #89, diagnosed with severe cognitive impairment, had a discrepancy in the morphine count, with 2 ml unaccounted for, and no dose was signed out on the Medication Administration Record (MAR). Similarly, Resident #90, also with severe cognitive impairment, had a 2.25 ml discrepancy in the morphine count, with no explanation provided for the missing medication. Resident #92, who had intact cognition, experienced a discrepancy in both morphine and Ativan counts. The Controlled Substance Count & Usage Record showed inconsistencies in the amounts recorded, with missing quantities not accounted for. Staff interviews revealed that Staff A, RN, was involved in these discrepancies, with reports of her appearing disoriented and potentially impaired during her shifts. Staff D, RN, refused to sign off on the narcotic counts due to the discrepancies and reported the issue to the Director of Nursing (DON). The facility's policy on abuse prevention and investigation was not followed, as the incidents were not properly investigated or reported. Staff members, including the previous DON, failed to take immediate action upon learning of the discrepancies. The facility's failure to adhere to its policy and ensure accurate medication counts resulted in the misappropriation of resident medications, compromising resident safety and care.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to securely store medications on one of its medication carts during observations. On January 7, 2025, at 10:39 AM, the medication cart in the 200 Wing was found unlocked in the lounge area, where five residents were present. Between 10:39 and 10:47 AM, four individuals walked by the unlocked cart. At 10:48 AM, an LPN returned from a resident's room and acknowledged that she typically does not leave the cart unlocked. Later, at 10:57 AM, the same cart was again found unlocked in the lounge, and at 10:59 AM, the LPN returned from the dining room area and locked the cart. The Director of Nursing confirmed that the expectation is for medication carts to be locked at all times. The facility's policy, dated October 2023, mandates that all medications and biologicals be stored in locked compartments with access restricted to authorized personnel.
Failure to Obtain Physician Orders for Wound Care
Penalty
Summary
The facility failed to provide necessary interventions and treatments for a resident with multiple skin breakdowns and did not obtain physician's orders for the treatments. The resident had active diagnoses including lymphedema, a stage III pressure ulcer, venous stasis ulcers, a non-pressure injury, and an infestation of maggots in the wounds. Recommendations for care included the application of various creams and dressings, repositioning, and avoiding incontinence briefs, but these were not followed due to the lack of physician orders. The resident was admitted with several skin issues, including pressure areas and moisture-associated skin damage, but the Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed no physician treatment orders for several days after admission. The Director of Nursing (DON) faxed the admission measurements to the physician but failed to follow up to obtain the necessary treatment orders. This oversight resulted in a delay in the transcription of verbal orders onto the MAR/TAR. Interviews with facility staff revealed that the Interim Administrator and the DON were aware of the missing treatment orders but did not take timely action to rectify the situation. The DON admitted to backdating orders to reflect when they should have been initiated. The facility's management team expected nurses to obtain physician orders for wound care, but this standard practice was not adhered to, leading to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cedar Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Specialty Care | 2.1 mi | ★★★★★ | 20 | 0 |
| West Ridge Care Center | 3.1 mi | ★★★★★ | 3 | 0 |
| Meth-wick Health Center | 4.1 mi | ★★★★★ | 0 | 0 |
| Living Center West | 5.4 mi | ★★★★★ | 2 | 0 |
| Harmony Cedar Rapids | 6.5 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.