The Gardens of Cedar Rapids, a state-licensed skilled-nursing facility. (Photo via Google Earth)
A Cedar Rapids nursing home where a registered nurse was reportedly stealing and then consuming residents’ painkillers while on duty is facing $1,000 in fines.
The Gardens of Cedar Rapids has been cited for a recordkeeping violation and resident abuse due to the facility’s failure to investigate and report an employee’s theft of residents’ painkilling medications.
According to state inspectors’ reports, video surveillance footage at the home shows that shortly after midnight on Sept. 19, 2024, a registered nurse took two boxes from the home’s medication cart and placed them in a bag. Around 7:30 p.m. that evening, the nurse carried a pink cup into the medication room while removing two boxes from her pocket.
She then went to a sink and placed some water into the cup, then removed a bottle from one of the boxes and dispensed drops of fluid into the cup. The video shows the nurse seated at the nurses’ station a few minutes later drinking from the cup, inspectors allege.
Two and a half hours later, just after 10 p.m., inspectors allege, the surveillance video shows the same nurse in the corner of the medication room with something in her right hand. She took a pink cup from the room, opened a small bottle, looked around, and then used a dropper to dispense drops of liquid into the cup. A minute later, the video allegedly captures her drinking from the cup.
At 11 p.m., the video captures the nurse standing at the medication cart, appearing to stagger, hanging onto a door, and swaying back and forth while another nurse cleans the medication room, the inspectors’ reports allege.
Worker: Nurse ‘popped pills all over the place’
A certified nurse’s aide later told inspectors that on the night in question she had been asked to help the registered nurse get to a place she could lie down and rest. The aide told inspectors that the nurse’s eyes were glassy, her speech was slurred, and she staggered as she walked. According to the inspectors’ written report, the aide likened the nurse to “a streetwalker that was going to fall over with their wobbly legs.” The nurse was taken to a conference room to sleep until 2 a.m. before leaving the building and going to her car where she apparently fell asleep or passed out.
A licensed practical nurse who worked that night told inspectors she had seen the registered nurse in the medication room with an opened bottle of Ativan or morphine that she had spilled, according to the inspectors’ report. The report states that the LPN reported the registered nurse seemed disoriented and had “popped pills all over the place, they were flying.”
The home’s restorative nurse told inspectors that when she arrived for work the morning of Sept. 20, she saw the registered nurse slumped over in the front seat of her car, asleep or passed out.
A week before that incident, a worker at the home had informed the director of nursing that the home’s inventory of narcotics for certain residents was “significantly lower” than what the registered nurse was claiming, and that the nurse appeared to be glassy eyed and falling asleep at work.
Inspectors later spoke to the director of nursing, who reported that she’d had no concerns with the nurses at the facility. She acknowledged that a staffer had texted her about morphine that was missing and unaccounted for but told inspectors she forgot to investigate the matter.
The home’s pharmacy later concluded that in addition to the morphine that was missing, there were oxycodone tablets were missing with no explanation as to where they went.
All three of the residents whose medications were stolen had been diagnosed with dementia, and one of the three had lung cancer, according to state records.
In 2023, the Iowa Department of Inspections, Appeals and Licensing had proposed, but then held in suspension, $25,250 in state fines against The Gardens of Cedar Rapids for failing to meet professional standards, inadequate quality of care, failure to treat pressure sores, medication and treatment errors and hazards in the environment. With the state fines held in suspension, the federal government later imposed $19,383 in civil penalties against the home.
In March 2024, the home was fined $500 by the state for failing to conduct adequate background checks on workers.