Cycle 1
Health 2025-01-09 · Fire 2025-01-09
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cedar Rapids, IA
The Gardens Of Cedar Rapids
3-star overall rating with 2-star inspections with $19,383 in total fines with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
5710 Dean Road SW, Cedar Rapids, IA
(319) 632-1469
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
37
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2017-11-06
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.87
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
3.80
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
3.32
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.62
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
4.10
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,378
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9932
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.64
Baseline 19.31% · Performance 19.75% · Measure score 3.64 · Achievement 3.64 · Improvement 0
Healthcare-associated infections
5.35
Baseline 6.88% · Performance 6.24% · Measure score 5.35 · Achievement 5.35 · Improvement 2.93
Total nurse turnover
2.45
Baseline 54.17% · Performance 53.66% · Measure score 2.45 · Achievement 2.45 · Improvement 0
Adjusted total nurse staffing
4.65
Baseline 4.12 hours · Performance 4.40 hours · Measure score 4.65 · Achievement 4.65 · Improvement 1.20
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.07% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 115 · Observed rate 8.7% · Lower 95% interval 6.9% |
| Discharge to community | 53.05% |
50.57%
2.5 pts better
|
No Different than the National Rate · Eligible stays 109 · Observed rate 48.62% · Lower 95% interval 45.3% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.52% |
95.27%
0.2 pts better
|
Numerator 64 · Denominator 67 |
| Falls with major injury | 1.49% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 67 |
| Discharge self-care score | 63.64% |
53.69%
10 pts better
|
Numerator 35 · Denominator 55 |
| Discharge mobility score | 52.73% |
50.94%
1.8 pts better
|
Numerator 29 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 10.45% |
2.29%
8.2 pts worse
|
Numerator 7 · Denominator 67 · Adjusted rate 12.17% |
| Healthcare-associated infections requiring hospitalization | 6.24% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 60 · Observed rate 3.33% · Lower 95% interval 3.47% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 116 |
| Staff flu vaccination coverage | 8.63% |
42%
33.4 pts worse
|
Numerator 17 · Denominator 197 |
| Discharge function score | 70.91% |
56.45%
14.5 pts better
|
Numerator 39 · Denominator 55 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 37 · Denominator 37 |
| Resident COVID-19 vaccinations up to date | 51.35% |
25.2%
26.2 pts better
|
Numerator 19 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.5
0.1 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
2.1
1.7 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
94.0%
2 pts better
|
93.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 88.5% · Q2 95.8% · Q3 100.0% · Q4 100.0% · 4Q avg 96.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.6% |
95.2%
1.4 pts better
|
95.5%
1.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.7%
3.7 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.0%
4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
4.9%
0.1 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.0% · Q3 5.0% · Q4 8.3% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.2% |
20.6%
11.4 pts better
|
19.6%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 5.0% · Q3 14.3% · Q4 8.0% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.9% |
19.8%
16.9 pts better
|
16.7%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 9.1% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.2% |
18.5%
1.7 pts worse
|
16.3%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.1% |
18.3%
0.2 pts better
|
14.9%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q3 35.0% · Q4 12.5% · 4Q avg 18.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.7%
1.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
2.5%
1.5 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.3% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.2% |
26.0%
4.2 pts worse
|
19.8%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 12.7% · Q3 39.1% · Q4 35.4% · 4Q avg 30.2% |
| Percentage of long-stay residents with pressure ulcers | 7.1% |
4.3%
2.8 pts worse
|
5.1%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 4.3% · Q3 7.9% · Q4 4.0% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
84.3%
14.9 pts better
|
81.7%
17.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 98.4% · Q3 100.0% · Q4 100.0% · 4Q avg 99.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.7% |
13.1%
1.4 pts better
|
12.0%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.7% · Observed 11.8% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.8% |
73.3%
17.5 pts better
|
79.7%
11.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.3% |
21.3%
5 pts better
|
23.9%
7.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 13.7% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-14 · Fire 2024-03-14
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cycle 3
Health 2023-01-18 · Fire 2023-01-18
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-09
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-02-19
F · Potential for more than minimal harm
2025-01-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-23
F · Potential for more than minimal harm
2025-01-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-01-23
F · Potential for more than minimal harm
2025-01-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-28
F · Potential for more than minimal harm
2025-01-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-14
F · Potential for more than minimal harm
2024-03-14
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-03-27
F · Potential for more than minimal harm
2024-03-14
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-03-28
F · Potential for more than minimal harm
2024-03-14
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-03-28
F · Potential for more than minimal harm
2024-03-14
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-03-29
F · Potential for more than minimal harm
2024-03-14
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-03-27
F · Potential for more than minimal harm
2024-03-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-26
F · Potential for more than minimal harm
2024-03-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-02
F · Potential for more than minimal harm
2024-03-14
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-03-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-01
F · Potential for more than minimal harm
2023-01-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-20
F · Potential for more than minimal harm
2023-01-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-20
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-09
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-09
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-09
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-09
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-09
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-09
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-08-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-03-14
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-04-04
D · Potential for more than minimal harm
2024-03-14
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-04-04
D · Potential for more than minimal harm
2024-03-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-04-04
G · Actual harm
2023-09-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-05
G · Actual harm
2023-09-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-05
G · Actual harm
2023-09-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-09-07
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-09-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-09-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-05
G · Actual harm
2023-01-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-01-19
D · Potential for more than minimal harm
2023-01-18
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-01-19
Penalties and ownership
What sits behind the stars
$19,383
2023-09-07
Fine
Fine · fine $19,383
Fine
Ownership
Angstman, James
5% Or Greater Indirect Ownership Interest · Individual
Michael, Chalee
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Heritage Specialty Care
Cedar Rapids, IA
1-star overall rating with 1-star inspections with $43,680 in total fines with 16 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
West Ridge Care Center
Cedar Rapids, IA
5-star overall rating with 5-star inspections with 5 fire-safety deficiencies in the latest cycle
#3
Meth-Wick Health Center
Cedar Rapids, IA
5-star overall rating with 5-star inspections with 4 fire-safety deficiencies in the latest cycle
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