Inspection Report Summary
The most recent inspection on June 5, 2025, identified deficiencies related to failure to follow established policies and procedures, including abuse reporting, incident documentation, staff training, food temperature monitoring, nurse’s notes, service plan updates, and current health care orders. Earlier inspections showed a pattern of similar issues with documentation, service plans, staff training, and tenant care, along with substantiated complaints of maltreatment and verbal abuse in November 2024. Prior complaint investigations also noted deficiencies in medication administration, staffing, evaluations, and service plans, with enforcement actions including a civil penalty of $4,500 and a conditional certificate issued in 2009; fines and license actions were not listed in the most recent reports. Most complaints were substantiated, especially those involving tenant care and staff conduct, while some earlier allegations were unsubstantiated. The facility’s inspection history shows recurring themes around documentation, staff training, and tenant care, with recent findings continuing similar patterns without clear improvement.
Deficiencies (last 14 years)
Deficiencies (over 14 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
32% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
17 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 17
Deficiencies: 4
Date: Jun 5, 2025
Visit Reason
The inspection was conducted to investigate Complaints #127441-C and #127464-C and to perform a recertification visit to determine compliance with certification of a Dedicated Dementia Specific Assisted Living Program.
Complaint Details
The visit was complaint-related, investigating allegations involving Tenant C1 including potential abuse by Staff C and issues with incident reporting and staff training.
Findings
The Program failed to follow established policies and procedures including timely reporting of potential abuse, completion of incident reports, dependent adult abuse training for staff, and proper food temperature monitoring. Additionally, deficiencies were found in documentation of nurse's notes, updating service plans to reflect tenant needs, and ensuring health care professional orders were current.
Deficiencies (4)
Failure to follow established policies and procedures including reporting allegations of potential abuse, completion of incident reports, dependent adult abuse training, and food temperature monitoring.
Failure to document nurse's notes by exception for one tenant.
Failure to update service plans as needed to reflect tenant needs for multiple tenants.
Failure to ensure health care professionals' orders were current for a discharged tenant receiving program-administered medications.
Report Facts
Census: 17
Incident report completion dates: 3
Staff training dates: 2
Food temperature readings: 5
Medication orders: 4
Service plans updated: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in findings related to failure to complete dependent adult abuse training timely and incomplete incident reporting | |
| Staff B | Named in findings related to failure to complete dependent adult abuse training timely | |
| Staff C | Named in abuse allegation involving Tenant C1 | |
| Healthcare Coordinator | Involved in reviewing abuse allegations and incident reports | |
| Executive Director | Involved in abuse allegation response and staff training | |
| Culinary Coordinator #1 | Reported food temperatures were taken but not recorded | |
| Culinary Coordinator #2 | Reported food temperatures were taken daily and recorded |
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 7
Date: Nov 26, 2024
Visit Reason
The inspection was conducted to investigate Incident #123918-I and Complaint #124909-C regarding regulatory insufficiencies related to food labeling and storage, tenant rights, staffing, evaluations, service plans, and nurse reviews at Arlington Place of Oelwein.
Complaint Details
The complaint investigation substantiated maltreatment and verbal abuse by Staff G towards tenants, failure to treat tenants with respect and dignity, and multiple failures in documentation, communication, evaluations, and service planning.
Findings
The program failed to follow its policies and procedures related to food labeling and storage, resulting in unlabeled and improperly stored food items. There were substantiated complaints of verbal abuse and maltreatment by staff, failure to ensure tenants were treated with respect and dignity, inadequate communication and documentation of tenant health status, incomplete evaluations and service plans, and failure to complete nurse reviews as required.
Deficiencies (7)
Program failed to follow policy and procedure related to food labeling and storage, affecting all tenants (census of 23).
Program failed to ensure tenants were treated with consideration, respect, and full recognition of personal dignity, involving maltreatment and verbal abuse by Staff G.
Program failed to communicate in writing occurrences that differed from a tenant's normal health, functional, and cognitive status and failed to retain documentation for at least three years.
Program failed to complete evaluations as needed with significant change for 3 of 4 tenants reviewed.
Program failed to update service plans to reflect identified needs of tenants for 4 of 4 tenants reviewed.
Program failed to complete nurse reviews as needed with changes in health status for 1 tenant reviewed who was hospitalized.
Program failed to discharge a tenant who exceeded retention criteria.
Report Facts
Total Census: 23
Number of tenants without cognitive disorder: 15
Number of tenants with cognitive disorder: 8
Number of tenants reviewed for evaluations: 4
Number of tenants reviewed for nurse communication documentation: 1
Number of tenants reviewed for nurse reviews: 1
Number of tenants reviewed for retention criteria: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Named in findings related to verbal abuse, maltreatment, and failure to follow policies | |
| Staff B | Witness and reporter in maltreatment and verbal abuse incidents | |
| Staff C | Witness and reporter in maltreatment and verbal abuse incidents | |
| Staff D | Witness and reporter in maltreatment and verbal abuse incidents | |
| Healthcare Coordinator | Interviewed regarding food labeling and maltreatment incidents | |
| Executive Director | Interviewed regarding maltreatment and staff behavior |
Inspection Report
Renewal
Census: 31
Deficiencies: 0
Date: Mar 1, 2023
Visit Reason
The visit was conducted as a recertification to determine compliance with certification rules for a Dementia-Specific Assisted Living Program and included investigation of related incidents and complaints.
Findings
No regulatory insufficiencies were cited during the recertification visit or during the investigation of Incident #107104-I, Complaint #110340-C, and Incident #107834-I.
Report Facts
Number of tenants without cognitive impairment: 25
Number of tenants with cognitive impairment: 6
Total census: 31
Inspection Report
Renewal
Census: 35
Deficiencies: 0
Date: Nov 27, 2018
Visit Reason
Recertification conducted to determine compliance with certification for a Dementia-Specific Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification for the Dementia-Specific Assisted Living Program.
Report Facts
Number of tenants without cognitive disorder: 26
Number of tenants with cognitive disorder: 0
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 9
TOTAL Census of Assisted Living Program for People with Dementia: 35
Inspection Report
Renewal
Census: 33
Deficiencies: 0
Date: Dec 7, 2016
Visit Reason
Recertification conducted to determine compliance with certification for an Assisted Living Program for People with Dementia (ALP/D).
Findings
No regulatory insufficiencies were cited during the recertification inspection of the Assisted Living Program.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 22
Number of tenants with cognitive disorder in General Population Program: 0
Total Population of General Population Program: 22
Number of tenants without cognitive disorder in Dementia-Specific Program: 2
Number of tenants with cognitive disorder in Dementia-Specific Program: 9
Total Population of Dementia-Specific Program: 11
Total census of Assisted Living Program: 33
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 0
Date: Apr 6, 2015
Visit Reason
The inspection was conducted as a complaint/incident investigation related to Incident #51647-I at Arlington Place of Oelwein.
Complaint Details
Allegation: Staffing - Findings: Unsubstantiated. Allegation: Level of care - Findings: Unsubstantiated.
Findings
The investigation found no regulatory insufficiencies. Allegations regarding staffing and level of care were both unsubstantiated based on tenant file reviews, staff interviews, and incident report reviews.
Report Facts
Number of tenants without cognitive disorder: 23
Number of tenants with cognitive disorder: 6
Total census: 29
Inspection Report
Monitoring
Census: 32
Deficiencies: 0
Date: Dec 4, 2014
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation to assess compliance with certification requirements for the Assisted Living Program at Arlington Place of Oelwein.
Findings
No regulatory insufficiencies were found during the evaluation, indicating full compliance with certification standards for the Assisted Living Program.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 23
Number of tenants with cognitive disorder in General Population Program: 0
Total Population of General Population Program: 23
Number of tenants without cognitive disorder in Dementia-Specific Program: 3
Number of tenants with cognitive disorder in Dementia-Specific Program: 6
Total Population of Dementia-Specific Program: 9
Total census of Assisted Living Program: 32
Inspection Report
Monitoring
Census: 25
Deficiencies: 0
Date: Sep 18, 2012
Visit Reason
The visit was a final recertification monitoring evaluation conducted to assess compliance with Iowa Administrative Code chapters 481-67 and 481-69 and to evaluate the Assisted Living Program at Arlington Place of Oelwein.
Findings
No regulatory insufficiencies were found during this evaluation. The program was found to be in compliance with all applicable regulations, and tenants expressed satisfaction with the services provided.
Report Facts
General Population Program tenants without cognitive disorder: 20
General Population Program tenants with cognitive disorder: 0
Total Population of General Population Program: 20
Dementia-Specific Program tenants without cognitive disorder: 5
Dementia-Specific Program tenants with cognitive disorder: 0
Total Population of Dementia-Specific Program: 5
Total census of Assisted Living Program: 25
Tenant meeting attendance: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Margaret Kaltefleiter | RN MS | Monitor conducting the final recertification monitoring evaluation |
Inspection Report
Monitoring
Census: 29
Deficiencies: 1
Date: Feb 17, 2011
Visit Reason
An on-site monitoring evaluation was conducted at Arlington Place of Oelwein to review the facility's compliance with regulatory requirements and the Plan of Correction following a prior evaluation.
Findings
The program did not receive any regulatory insufficiencies during this certification period. Tenant satisfaction was generally positive, though a regulatory insufficiency was noted for failure to report a major injury within 24 hours.
Deficiencies (1)
Failure to report a major injury to the department within 24 hours or the next business day as required by regulation.
Report Facts
Current number of tenants without cognitive disorder: 29
Current number of tenants with cognitive disorder: 0
Total Population: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deanna Kahler | Manager | Named as facility manager in report |
| Stephanie Cummins | Monitor | Conducted the monitoring evaluation |
| Rose Boccella | Program Coordinator | Signed letter transmitting report |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 4
Date: Aug 19, 2010
Visit Reason
A complaint investigation on-site visit was conducted at Arlington Place of Oelwein on August 19, 2010, to assess regulatory insufficiencies related to medications, food service, staffing, and record checks.
Complaint Details
The complaint investigation was substantiated with regulatory insufficiencies found in medications, food service, staffing, and record checks. Some allegations such as lack of training and telephone availability were not substantiated.
Findings
The investigation identified multiple regulatory insufficiencies including medication administration errors, kitchen cleanliness issues, insufficient staff training documentation, and incomplete background checks. Some allegations were substantiated while others were not noted as deficient.
Deficiencies (4)
Medication administration errors including missing signatures on MAR, transcription errors, and improper documentation.
Kitchen cleanliness issues such as burnt residue, uncovered waste basket, debris under counters, and ice machine smears.
Insufficient documentation of nurse delegation training for wound dressing changes.
Positive criminal history found for an employee without evidence of approval prior to hire.
Report Facts
Civil penalty amount: 2500
Civil penalty reduced amount: 1625
Number of tenants without cognitive disorder: 29
Number of tenants with cognitive disorder: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 7
Date: Mar 31, 2009
Visit Reason
The inspection was conducted as a final complaint investigation related to allegations concerning Evaluation of Tenants, Service Plans, Medications, Nurse Review, Staffing, Managed Risk, and Other tenant autonomy issues at Arlington Place Assisted Living of Oelwein.
Complaint Details
The complaint investigation was substantiated with findings of regulatory insufficiencies in multiple areas including medications, tenant evaluations, service plans, nurse review, staffing, and managed risk. The program was issued a conditional certificate and a civil penalty of $4,500 was imposed.
Findings
The investigation found multiple regulatory insufficiencies in areas including medication administration, tenant evaluations, service plans, nurse review, staffing, and managed risk statements. A conditional certificate was issued and a civil penalty of $4,500 was assessed.
Deficiencies (7)
Failure to consistently evaluate tenants' cognitive and functional abilities and health status as needed.
Failure to consistently update individualized service plans reflecting tenants' needs and requests.
Failure to consistently provide administration of medications by licensed nurses and proper documentation.
Failure to complete nurse reviews and assessments as required.
Failure to provide sufficient trained staff to meet tenants' identified needs.
Failure to provide a managed risk statement including tenant or legal representative's signed acknowledgement.
Failure to encourage family involvement, tenant self-direction, and participation in decisions emphasizing choice and independence.
Report Facts
Civil penalty amount: 4500
Current number of tenants without cognitive disorder: 23
Current number of tenants with cognitive disorder: 2
Total population: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janet Sandell | Interim Housing Director | Named as recipient of the report and involved in program oversight. |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the final complaint investigation report letter. |
| Vickie Clingan | RN MA | Monitor involved in the complaint investigation. |
| Stephanie Cummins | MA | Monitor involved in the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 3
Date: Jan 28, 2009
Visit Reason
A complaint investigation on-site visit was conducted at Arlington Place Assisted Living of Oelwein on January 28, 2009, regarding regulatory insufficiencies in medications, nurse review, and staffing.
Complaint Details
The complaint investigation was substantiated with findings of regulatory insufficiencies in medications, nurse review, and staffing.
Findings
The investigation found regulatory insufficiencies in the administration of medications, nurse review, and staffing, including inconsistent medication administration by licensed nurses, incomplete health care professional orders, and insufficient trained staff to meet tenants' needs.
Deficiencies (3)
The program did not consistently provide the administration of medications by an Iowa-licensed registered nurse or authorized agent as prescribed by the physician.
The program did not consistently ensure that health care professionals' orders for tenants receiving health care professional-directed care were current.
The program did not consistently provide sufficient trained staff available at all times to fully meet tenants' identified needs.
Report Facts
Census: 24
Civil penalty amount: 2500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Conducted the complaint investigation |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the final complaint investigation report letter |
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 5
Date: Dec 15, 2008
Visit Reason
The visit was a final recertification revisit and complaint investigation conducted at Arlington Place Assisted Living of Oelwein on December 15, 2008, triggered by Complaint #20400-C.
Complaint Details
Complaint allegations included that the program administrator told residents and staff not to talk to former staff. Investigations found no regulatory insufficiency related to these allegations.
Findings
The investigation found substantiated regulatory insufficiencies related to evaluation of tenants, service plans, nurse review, and staffing. No new regulatory insufficiencies were noted regarding interference with the investigation or prohibition of staff talking to former staff. The Plan of Correction submitted was accepted by the Department of Inspections and Appeals.
Deficiencies (5)
The program did not consistently complete functional, cognitive, and health evaluations as needed and annually for tenants.
The program did not consistently complete or update individualized service plans for tenants as required.
The program did not consistently ensure physician orders were current and assess/document tenants' health-related activities.
The program did not consistently provide sufficiently trained staff to meet tenants' identified needs.
The program did not consistently follow the written Plan of Correction submitted regarding the recertification visit.
Report Facts
Current number of tenants without cognitive disorder: 22
Current number of tenants with cognitive disorder: 0
Total Population: 22
Tenants in attendance at community meeting: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristi Steinlage | Housing Manager | Addressee and facility representative |
| Hal L. Chase | RN BSN MPH | Monitor conducting the investigation |
| Chris Nothaft | Certification Coordinator – Eastern Iowa | Signed acceptance of Plan of Correction |
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 5
Date: Sep 18, 2008
Visit Reason
An on-site monitoring evaluation and complaint investigation visit was conducted at Arlington Place Assisted Living of Oelwein on September 18, 2008, to review regulatory compliance and investigate complaints.
Complaint Details
Complaint intake #18818 involved allegations of kitchen and dining room areas being filthy, pans soaking overnight, insufficient food quantity and quality, and ice cream served daily for dessert. These allegations were not substantiated upon investigation.
Findings
The investigation found substantiated regulatory insufficiencies in the areas of Service Plans, Medications, Staffing, and Managed Risk. Tenant interviews indicated satisfaction with food, activities, and safety, but documentation and evaluation deficiencies were noted. No issues were found with food service cleanliness or meal adequacy. Staffing training was insufficient in some areas.
Deficiencies (5)
The program did not consistently evaluate each tenant's functional, cognitive, and health status as needed and annually.
The program did not update service plans as needed or based on evaluations, and did not ensure multidisciplinary team involvement.
The program did not ensure health care professionals' orders for medications were current and properly documented.
The program did not consistently provide sufficient trained staff to meet tenants' identified needs.
The program prevented or interfered with a duly authorized representative of the department of inspections and appeals in enforcement of rules.
Report Facts
Current number of tenants without cognitive disorder: 22
Current number of tenants with cognitive disorder: 0
Total Population: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | SW MA | Monitor conducting the complaint investigation |
| Kristi Steinlage | Housing Manager | Named as facility contact and in relation to Plan of Correction |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 4
Date: May 9, 2005
Visit Reason
A complaint investigation on-site visit was conducted at Arlington Place on May 9, 2005 to investigate allegations that the program did not appropriately assess tenants, retained tenants beyond an appropriate level of care, did not have appropriately signed service plans, and did not have adequate supervision of tenants.
Complaint Details
The complaint investigation was triggered by allegations that the program failed to appropriately assess tenants, retained tenants beyond appropriate level of care, lacked signed service plans, and had inadequate supervision of tenants. The complaint was not substantiated in prior certification periods.
Findings
The investigation found multiple regulatory insufficiencies including failure to evaluate each tenant’s functional, cognitive, and health status prior to occupancy and annually; retention of tenants beyond appropriate level of care without transfer; lack of appropriately signed service plans; and insufficient staffing to meet tenant needs, including inadequate supervision and difficulty contacting the RN.
Deficiencies (4)
The program did not evaluate each tenant’s functional and cognitive abilities and health status prior to taking occupancy, within 30 days, annually and as needed with a change in condition.
The program did not initiate transfer for tenants who on a routine basis have unmanageable incontinence or are dangerous to self.
The program did not have appropriately signed service plans.
The program did not have enough staff to sufficiently meet the needs of the tenants.
Report Facts
Current number of tenants without cognitive disorder: 20
Current number of tenants with cognitive disorder: 9
Total tenants present: 29
Tenants hospitalized: 5
Emergency response pendant uses: 4
Falls: 4
Building unattended duration: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Social Worker (SW) MA | Monitor conducting the complaint investigation |
Inspection Report
Monitoring
Census: 17
Deficiencies: 2
Date: Aug 12, 2004
Visit Reason
The on-site monitoring evaluation was conducted as part of a re-certification monitoring visit to assess compliance with Iowa Administrative Code regulations for assisted living programs.
Findings
The evaluation found regulatory insufficiencies related to tenant evaluations and service plans, including failure to complete and document evaluations and service plans prior to occupancy, and missing cognitive evaluations for tenants with dementia.
Deficiencies (2)
The program did not perform and accurately document tenant evaluations prior to occupancy and did not perform cognitive evaluations when needed.
The program did not develop service plans prior to occupancy.
Report Facts
Current number of tenants without cognitive disorder: 14
Current number of tenants with cognitive disorder: 3
Total General Population: 17
Tenant records reviewed: 5
Tenant records missing evaluations prior to occupancy: 4
Tenants with dementia missing GDS evaluation: 2
Tenant records missing service plans prior to occupancy: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beverly A. Johnson | RN | Monitor conducting the on-site monitoring evaluation |
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