Cottage Grove Place
2115 First Avenue SE, Cedar Rapids, IA 52402 · Linn County · 64 certified beds · avg 54 residents/day · certified since May 7, 1997
Part of chain: LIFE CARE SERVICES (43 facilities, chain avg rating 4.1★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Apr 14, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: May 8, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 6, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 23, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (23)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 14, 2026 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 6, 2026 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 1, 2025 | E · Potential for harm, repeated | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| May 1, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 1, 2025 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Sep 30, 2024 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Sep 30, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · from a complaint |
| Aug 1, 2024 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Jul 9, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jul 9, 2024 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Jul 9, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jul 9, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Jul 9, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jul 9, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jul 9, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jul 9, 2024 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| Jul 9, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jul 9, 2024 | D · Potential for harm, one-off | The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. · from a complaint |
| Feb 5, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Feb 5, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| May 4, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| May 4, 2023 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| May 4, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (10 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 3 | 0 | D |
| 2024 | 15 | 0 | E |
| 2025 | 3 | 0 | E |
| 2026 | 2 | 2 | J ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Iowa avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.57 | 4.37 | 3.95 | top 36% in Iowa; top 21% in the U.S. |
| Registered Nurse hours | 0.61 | 0.85 | 0.69 | bottom 23% in Iowa; top 47% in the U.S. |
| Weekend total nurse staffing | 4.20 | 3.86 | 3.50 | top 31% in Iowa; top 18% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.41 | 0.51 | 0.48 | bottom 39% in Iowa; top 47% in the U.S. |
| Total nursing staff turnover (%) | 38.6 | 44.0 | 45.8 | top 41% in Iowa; top 33% in the U.S. |
| RN turnover (%) | 45.5 | 42.1 | 42.9 | bottom 43% in Iowa; bottom 43% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.23, RN 0.56, weekend 3.89. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 2/5 · short-stay residents: 5/5
Who owns this facility
Non profit - Other
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Cottage Grove Place | Organization | 5% or Greater Direct Ownership Interest | 100% | 10/01/1996 |
| Cooper, Tad | Individual | Corporate Director | NOT APPLICABLE | 09/29/2011 |
| Cooper, Tad | Individual | Corporate Officer | NOT APPLICABLE | 09/19/2019 |
| Cottage Grove Place | Organization | Operational/Managerial Control | NOT APPLICABLE | 09/14/1992 |
| First Interstate Bank | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 08/01/2012 |
| Hattery, Michael | Individual | Corporate Director | NOT APPLICABLE | 06/30/2021 |
| Landis, Clint | Individual | Corporate Director | NOT APPLICABLE | 09/01/2022 |
| Landis, Richard | Individual | Corporate Director | NOT APPLICABLE | 09/24/2021 |
| Landis, Richard | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2025 |
| Lenzen, Philip | Individual | Corporate Director | NOT APPLICABLE | 09/18/2019 |
| Life Care Services LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Life Care Services LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/23/2025 |
| McCartan, William | Individual | Corporate Director | NOT APPLICABLE | 09/01/2024 |
| Meiborg, Tory | Individual | Corporate Director | NOT APPLICABLE | 09/21/2018 |
| Nassif, Jana | Individual | Corporate Director | NOT APPLICABLE | 09/22/2023 |
| Sherman, Edward | Individual | Corporate Director | NOT APPLICABLE | 05/20/2022 |
| Sherman, Edward | Individual | Corporate Officer | NOT APPLICABLE | 05/20/2022 |
| Smithson, Leland | Individual | Corporate Director | NOT APPLICABLE | 09/18/2019 |
| Snook, Jennifer | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/07/2025 |
| Snook, Jennifer | Individual | ADP of the SNF | NOT APPLICABLE | 04/22/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How is your kitchen staffed, and have meals ever been delayed because of staffing?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "What is your approach to psychiatric medications — how do you try non-drug options first and work to reduce doses over time?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Harmony Cedar Rapids | 0.3 mi | Cedar Rapids, IA | ★☆☆☆☆ | 1/5 | |
| Living Center West | 1.4 mi | Cedar Rapids, IA | ★★☆☆☆ | 2/5 | |
| St Luke's Helen G Nassif Transitional Care Center | 2.3 mi | Cedar Rapids, IA | ★★★★★ | 4/5 | |
| Linn Manor Care Center | 2.4 mi | Marion, IA | ★★☆☆☆ | 2/5 | |
| Meth-Wick Health Center | 3.0 mi | Cedar Rapids, IA | ★★★★★ | 5/5 | |
| Northbrook Healthcare and Rehabilitation Center | 3.3 mi | Cedar Rapids, IA | ★☆☆☆☆ | 1/5 | |
| Silver Oak Nursing and Rehabilitation Center LLC | 3.8 mi | Marion, IA | ★☆☆☆☆ | 1/5 | |
| Oakview Nursing & Rehablitation - Marion | 4.0 mi | Marion, IA | ★★★★☆ | 4/5 | |
| West Ridge Care Center | 4.0 mi | Cedar Rapids, IA | ★★★★★ | 5/5 | |
| Terrace Glen Village | 4.2 mi | Marion, IA | ★★★★★ | 4/5 | |
| Hiawatha Care Center | 4.2 mi | Hiawatha, IA | ★★★☆☆ | 3/5 | |
| Hallmar Village | 4.3 mi | Cedar Rapids, IA | ★★☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 165322.