Heritage Specialty Care
Heritage Specialty Care in Cedar Rapids, IA — inspection on May 28, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the electronic health record (EHR) Clinical Census information for Resident #13 revealed an entry of hospital paid leave effective 3/28/26.
A Progress Note dated 3/29/26 at 6:34 AM documented Resident #13 had been admitted to the hospital.
Review of the Notice of Transfer Form to Long Term Care Ombudsman lacked Resident #13's 3/28/26 hospitalization.
Review of the EHR Clinical Census information for Resident #126 revealed an entry of hospital paid leave effective 2/24/26 and an entry of stop billing effective 2/28/26.
A Progress Note dated 2/24/26 at 1:56 PM documented Resident #126 had been sent to the emergency room for surgical opinion.
The Progress Notes lacked documentation Resident #126 had been admitted to the hospital.
A Progress Note dated 2/27/26 at 12:00 PM documented Resident #126 was being discharged .
Review of the Notice of Transfer Form to Long Term Care Ombudsman lacked Resident #126's 2/24/26 hospitalization and the 2/28/26 discharge.
During an interview on 5/6/26 at 9:42 AM, Staff A, Interim Social Services reported Resident #13 and Resident #126 had not been included on the Notice of Transfer Form to Long Term Care Ombudsman.
During an interview on 5/6/26 at 12:05 PM, the Administrator revealed the facility lacked a policy and acknowledged Resident #13 and #126 should have been included in the notifications to the LTC Ombudsman.
Review of the EHR Clinical Census information for Resident #122 revealed an entry of hospital unpaid leave effective 3/26/26.
A Progress Note dated 3/26/26 at 6:50 PM documented Resident #122 had been admitted to the hospital.
The Notice of Transfer Form to Long Term Care Ombudsman lacked Resident #122's 3/26/26 hospitalization.
165310 05/28/2026
Heritage Specialty Care 200 Clive Drive SW Cedar Rapids, IA 52404
responsible for completing the MDS.
Staff B acknowledged Resident #105 has had a feeding tube
reflect the resident condition.
The MDS Completion and Submission Timeframes facility policy revised July 2017 revealed the Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to [redacted] system in accordance with current Federal and State Guidelines.
165310 05/28/2026
Heritage Specialty Care 200 Clive Drive SW Cedar Rapids, IA 52404
Review of Resident #84's Care Plan focus area dated 5/6/25 revealed the resident received hemodialysis related to end stage renal disease (ESRD), and had an arteriovenous (AV) fistula to the left upper extremity (LUE).
The Intervention dated 5/6/25 revealed staff to listen to and feel the dialysis site (the fistula) to ensure it was functioning correctly.
This was required before dialysis, after dialysis, and on days without dialysis.During an observation and interview on 5/5/2026 at 8:17 AM, Resident #84 explained that while nurses checked her vital signs before she left for dialysis, they often failed to check her afterward or on days when she didn't have an appointment. Resident #84 pulled up her left sleeve and showed the fistula site.
She expressed that this worried her because she was afraid of medical complications. In a follow-up interview the next day on 5/6/2026 at 8:32 AM, she noted that no one had checked her dialysis access site at all the previous day.
She felt ignored.Review of Resident #84's electronic medical records showed the following present on the resident's April 2026 Supplemental Documentation Record: a.
Complete the Dialysis Evaluation prior to dialysis, post dialysis and on non-dialysis days. every day shift every Tues, Thurs, Sat, Sun.b.
Complete the Dialysis Evaluation prior to dialysis, post dialysis and on non-dialysis days. two times a day every Mon, Wed, Fri.
Records revealed the following: On 4/16/2026 and 4/26/2026 (non-dialysis days), nurses signed off the assessment was done, but the actual evaluation data was missing. On 4/17/2026 (dialysis day), the facility failed to perform the required check after the resident returned from treatment.
During an interview on 5/06/2026 at 9:11 AM Staff F, LPN (Licensed Practical Nurse) confirmed that staff were expected to evaluate dialysis residents every day.
This included checking the dialysis site for a thrill and bruit (the vibration and sound that indicate the site was working properly) and vital signs.
Staff F stated that these checks were supposed to happen before and after every dialysis appointment.
During an interview on 5/06/2026 at 12:25 PM, the Director of Nursing (DON) stated that all staff had received online training for dialysis care.
The DON acknowledged that while nurses were supposed to assess residents both before and after their appointments, the post-dialysis checks did not always happen.
The DON also mentioned that daily checks on non-dialysis days only occurred if a doctor specifically ordered them, and any missed checks should have been documented as refused or noted if the resident was out of the building
Review of the facility policy titled End-Stage Renal Disease, Care of a Resident with last revised September 2010 revealed staff caring for residents with ESRD, including residents receiving dialysis care outside of the facility, shall be trained in the care and special needs of these residents.
Education and training of staff includes, specifically the type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis.
165310 05/28/2026
Heritage Specialty Care 200 Clive Drive SW Cedar Rapids, IA 52404
meet the behavioral health needs of residents.
history, PTSD triggers, signs of distress, non-pharmacological interventions, or medication in
(Resident #112).
The facility reported a census of 127 residents.Findings include:admission paperwork for Resident #112 scanned to the facility on 2/20/2026 documented the resident took 1 milligram (mg) of prazosin at bedtime for chronic PTSD with trauma related nightmares. Resident #112's care plan with an admission date of 3/02/2026 did not include focus areas, goals, or interventions for PTSD, nightmares, trauma, or prazosin.The Minimum Data Set (MDS) for Resident #112 dated 3/08/2026 documented a Brief Interview for Mental Status score of 3/15 which indicated severe cognitive impairment. MDS diagnoses included non-Alzheimer's dementia, anxiety disorder, and depression.
The box for PTSD was not checked.A document titled Progress Notes dated 4/07/2026 revealed the resident's provider conducted a regulatory visit at the facility.
The past medical history did not include PTSD.The task section of the Electronic Health Record (EHR) included monitoring behavior symptoms. A 30 day look back revealed that on 4/13/2026 the resident was documented crying, yelling, pushing, and grabbing. On 04/16/2026 the facility documented the resident yelled/screamed.The resident's Medication Administration Record (MAR) for May 2026 retrieved 5/04/2026 at 1:47 PM documented the resident received prazosin HCl oral capsule 1 mg by mouth one time a day for chronic PTSD with night terrors.
The MAR did not include behavior monitoring.On 5/04/2026 at 11:04 AM observed the resident call out from her bed with the sound ah ah ah ah ah ah.
Her speech was mostly garbled then she clearly stated her head hurt.
The resident closed her eyes and called out again in a higher pitch.
Her head moved back and forth on the pillow.On 5/06/26 at 7:42 AM heard resident hum then call out with a loud, repetitive sound.
After about a minute she yelled, ahhhhhhhh.At 9:12 AM on 5/07/2026 Staff I, Licensed Practical Nurse (LPN) indicated staff monitor for agitation, aggressive behavior, and residents seeking a lot of attention.
She reported Resident #112 yelled and screamed sometimes when she was out of her room and called out when she was in bed, and she didn't really know what caused it.
She stated it was addressed with scheduled and as needed medications.
She was not aware of a PTSD diagnosis or nightmares/night terrors.
She would address it by sitting with a resident and reassure them if she knew it was happening.
During an interview on 5/07/2026 at 9:23 AM Staff J, Certified Nurses Aide (CNA) stated she watched residents for threatening, combative, sexual, emotional, and health changes and reported them to the nurse.
Staff J reported it was normal for this resident to call out.
She wasn't sure what caused it.
When asked if she was aware of the resident's PTSD diagnosis or night terrors, she stated she didn't know about that because she didn't work at night.
She didn't think it happened during the day, only when she did that 'screaming out thing' maybe.On 5/07/2026 at 10:04 AM Staff K, Assistant Director of Nursing (ADON) confirmed the resident's EHR did not include a diagnosis of PTSD.
Because the resident was on a medication for PTSD, the ADON stated she would expect it to show on the list of diagnoses, the care plan, the MDS, and hospice information.
She thought the facility would be responsible for identifying triggers, monitoring mood and behaviors, would have regular behavior documentation, should know what led to the PTSD diagnosis, and have a plan for non-pharmacological interventions.
She was unable to find that in the resident's EHR.On 5/07/2026 at 10:38 AM the DON confirmed the resident was on prazosin for chronic PTSD with night terrors.
She reported the resident admitted to the facility from home and coordination could be difficult.
She wasn't sure about the cause of the PTSD or triggers, and stated the social worker who would have addressed that was no longer there. At 12:22 PM, she stated they did locate the diagnosis on the admission orders and confirmed it did not get transferred to the resident's EHR.
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Heritage Specialty Care 200 Clive Drive SW Cedar Rapids, IA 52404
Review of the employee file for Staff C contained a Job Description for the position of Cook, which listed Staff C's date of hire as 1/26/26.
The Job Description directed staff to handle and prepare food in a sanitary manner, and to maintain strict compliance with established policy/practices/standards for food preparation and storage.
Staff C signed the Job Description on 5/6/26.
Review of the Order Listing Report with a date of 5/5/26 listed 6 residents with pureed diet texture.
Review of the Food Preparation and Service facility policy revised April 2019 directed staff to adhere to proper hygiene and sanitary practices to prevent the spread of food borne illness.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
165310 05/28/2026
Heritage Specialty Care 200 Clive Drive SW Cedar Rapids, IA 52404
Based on interviews, record review, and policy review the facility failed to maintain documentation of
status.
The facility reported a census of 127 residents.Findings include:On 5/07/2026 at 10:16 AM Staff K, Assistant Director of Nursing (ADON), stated she was the facility's infection preventionist.
When asked when staff received education regarding COVID testing and vaccination, she stated the same provider who vaccinated residents could give the education to staff.
Staff K did not have documentation of who received that education.
She indicated she would have to see if there was COVID training in (redacted) their training platform or during orientation because she wasn't involved in all of that.
During an interview on 5/07/2026 at 10:38 AM the Director of Nursing (DON) reported the staff received COVID education through (redacted) their training provider.
The DON directed back to Staff K for documentation regarding COVID based on her role as infection preventionist. A document titled 2026 Annual CNA (Certified Nurses Aide) Training Schedule updated 02/16/2026 documented staff training by quarter.
The list did not include COVID education. An email from the Administrator, dated 05/07/2026 at 11:39 AM included a COVID-19 fact sheet dated 1/31/2025.
She indicated that was their COVID education.
She did not include information about when staff were provided the education, who received it, how often, or how staff were screened.
During an interview on 5/07/2026 at 12:19 PM Staff H, Certified Medication Aide (CMA) stated she had worked at the facility for about 2 years.
She reported she was not asked by the facility for her vaccination status, was not offered the COVID vaccine or told where to get one, and the facility did not provide COVID education to her on paper or in person.
She thought there might have been a training online but she couldn't remember when.
During a follow up interview with Staff K on 5/07/2026 at 12:23 PM she stated she couldn't say if they had any additional documentation that staff were screened for vaccination eligibility, provided COVID education, were offered the vaccine or told where to get it, or if the facility administered the vaccine to any staff through their vaccination partner. A policy titled Coronavirus Disease (COVID-19) - Vaccination of Residents and Staff dated February 2021 indicated staff eligible to receive the COVID-19 vaccine were strongly encouraged to do so.
Staff consent would be documented in the employee health record.
Staff would be provided a fact sheet specific to the vaccine he or she will receive that explained risks and benefits, contraindications, and potential side effects or adverse reactions.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.