Inspection Report Summary
The most recent inspection on April 24, 2025, found deficiencies related to incomplete policies and procedures for incident reporting, medication administration, service plans, documentation, and food safety. Earlier inspections showed a pattern of issues with medication administration, service plan documentation, staff training, and incident reporting. Complaint investigations substantiated concerns about medication errors, chemical restraints, and failure to report suspected abuse, resulting in staff termination and re-education, but no fines or license actions were listed in the available reports. Most complaints were substantiated, focusing on medication management, staff training, and documentation, while some complaints were found unsubstantiated. The inspection history indicates ongoing challenges with regulatory compliance, with deficiencies persisting over time and no clear trend of sustained improvement.
Deficiencies (last 15 years)
Deficiencies (over 15 years)
4.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
7% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
16 residents
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 9
Date: Apr 24, 2025
Visit Reason
The inspection was conducted as a complaint investigation and review of regulatory insufficiencies related to complaints #124468-C, #127787-C, and incident #125841-I.
Complaint Details
The investigation was related to complaints #124468-C and #127787-C and incident #125841-I. There were no regulatory insufficiencies identified related to complaint #125118-C.
Findings
The program failed to have complete policies and procedures for incident reporting, medication administration, service plans, documentation, and food safety. Multiple incidents lacked proper documentation, medication administration was not consistently recorded, and food safety protocols were not fully followed. Staff training and service plan updates were also deficient.
Deficiencies (9)
The program failed to have a detailed incident report policy and did not document incidents on incident report forms for multiple tenants.
The program failed to follow policies and procedures regarding head injuries, service documentation, and dining services.
The program failed to keep physician-ordered nutritional supplements in a locked place inaccessible to others outside of staff.
The program failed to administer medications as ordered and failed to document medication administration properly for multiple tenants.
The program failed to ensure staff provided services in accordance with dementia training.
The program failed to complete evaluations as needed for tenants with significant changes.
The program failed to obtain and maintain accurate medication lists for tenants.
The program failed to provide orientation and annual training on sanitation and safe food handling to food service staff.
The program failed to ensure potentially hazardous foods were cooked and held at safe temperatures.
Report Facts
Total census: 16
Number of tenants with cognitive impairment: 16
Number of tenants without cognitive impairment: 0
Number of deficiencies cited: 9
Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 3
Date: Oct 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation into allegations related to medication administration and potential abuse at Brown Deer Place, an assisted living program for people with dementia.
Complaint Details
The complaint investigation was triggered by allegations that Staff A administered higher doses of Risperidone than prescribed to Tenant #1 and failed to report the medication errors and suspected abuse in a timely manner. The investigation substantiated these concerns, leading to Staff A's termination and re-education of all staff.
Findings
The investigation found that staff failed to follow medication administration policies, including giving a tenant (Tenant #1) more Risperidone medication than prescribed and storing medications in unlocked areas accessible to tenants. Staff also failed to report suspected abuse promptly. Tenant #1 was subjected to chemical restraints without proper safeguards, and staff behavior toward the tenant was inappropriate.
Deficiencies (3)
Failure to follow program policies on Medication and Medication Administration and Adult Abuse Reporting for Tenant #1.
Failure to ensure Tenant #1 was free from chemical restraints, exposing her to inappropriate medication dosing.
Failure to store medications in a locked area, allowing tenant access to medications.
Report Facts
Total census: 16
Number of tenants without cognitive impairment: 3
Number of tenants with cognitive impairment: 13
Unaccounted Risperidone medication (ml): 90
Risperidone prescribed dose: 0.5
Risperidone overdose observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Terminated for administering excess medication and failing to report abuse; involved in medication errors and inappropriate behavior toward Tenant #1. | |
| Staff B | Witnessed Staff A's medication errors and reported concerns but delayed notifying nurse and management. | |
| Staff C | Observed medication errors and inappropriate administration times; aware of Staff A's behavior but did not report concerns. | |
| Staff D | Observed medication administration irregularities and Staff A's agitation with Tenant #1 but did not report concerns. | |
| Staff E | Reported Staff A's inappropriate behavior toward Tenant #1. | |
| Executive Director | Confirmed findings of the investigation. | |
| Regional Nurse Specialist | Provided expert opinion on medication administration errors and policy violations. | |
| Former Health Care Coordinator | Reported observations about Tenant #1's condition and medication issues during brief employment. |
Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 1
Date: Oct 9, 2024
Visit Reason
The inspection was conducted as part of the investigation of Complaint #123059-C regarding regulatory compliance at the assisted living program.
Complaint Details
Investigation of Complaint #123059-C found failure to ensure signed and dated service plans for Tenant 2.
Findings
The program failed to ensure that the service plan was signed and dated for 1 of 4 tenants reviewed (Tenant 2). The service plan for Tenant 2 was unsigned and undated since admission.
Deficiencies (1)
Service plan was not signed and dated for Tenant 2 as required.
Report Facts
Number of tenants without cognitive impairment: 3
Number of tenants with cognitive impairment: 13
Total census: 16
Number of tenants reviewed: 4
Number of tenants with unsigned service plans: 1
Inspection Report
Complaint Investigation
Census: 17
Deficiencies: 2
Date: Apr 16, 2024
Visit Reason
The inspection was conducted as a complaint investigation into multiple complaints (#115147-C and #116487-C) regarding the assisted living program for people with dementia at Brown Deer Place.
Complaint Details
No regulatory insufficiencies were cited during the investigation into Complaint #116587-C, Incident #117795-I, Complaint #117824-C, or Complaint #118690-C. Regulatory insufficiencies were cited during the investigation into Complaint #115147-C and Complaint #116487-C.
Findings
The investigation found that the program failed to produce detailed incident reports for 2 of 6 discharged tenants and failed to ensure service plans addressed the needs of current and discharged tenants. No regulatory insufficiencies were cited for other complaints investigated.
Deficiencies (2)
The program failed to produce detailed incident reports involving 2 of 6 discharged tenants (Tenant C1 and Tenant C2).
The program failed to ensure service plans addressed the needs of 1 of 4 current tenants (Tenant #4) and 2 of 5 discharged tenants (Tenant C1, Tenant C2).
Report Facts
Number of tenants without cognitive impairment: 5
Number of tenants with cognitive impairment: 12
Total census: 17
Discharged tenants with deficient incident reports: 2
Current tenants with deficient service plans: 1
Discharged tenants with deficient service plans: 2
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 12
Date: Aug 17, 2023
Visit Reason
The inspection was conducted to investigate complaints #112945-C and #114783-C and to conduct a recertification visit for compliance with certification of a Dedicated Dementia Specific Assisted Living Program.
Complaint Details
The inspection included investigation of complaints #112945-C and #114783-C. No regulatory insufficiencies were cited related to complaint #114420-C.
Findings
The Program failed to follow established policies related to incident report completion, medication administration by qualified staff, consistent medication administration as prescribed, timely nurse delegation training, proper service plan updates and signatures, dementia-specific training within 30 days of hire, dependent adult abuse training within six months, and ensuring drivers had appropriate licenses. No regulatory insufficiencies were found related to complaint #114420-C.
Deficiencies (12)
Failure to follow established policy and procedure related to the completion of incident reports for tenants.
Medications were administered by staff who had not completed an approved medication manager course.
Medications and treatments were not consistently administered as prescribed for multiple tenants.
Staff failed to receive nurse delegated training within 30 days of employment.
Staff failed to provide services in accordance with training, including improper glove use and hand hygiene during blood glucose monitoring and insulin administration.
Staff failed to receive required dependent adult abuse training within six months of employment.
Program failed to obtain an evaluation of a founded child abuse prior to employment for one staff member.
Failed to consistently complete evaluations as needed with significant change in tenant condition, including a tenant who sustained a fall with fracture.
Failed to consistently update service plans as needed and failed to develop service plans reflecting identified needs of tenants.
Failed to obtain signed service plans when a significant change occurred for current and discharged tenants.
Failed to ensure staff completed eight hours of dementia-specific education and training within 30 days of hire.
Failed to ensure staff transporting tenants had appropriate driver licenses for the vehicles used.
Report Facts
Total census: 14
Number of tenants without cognitive impairment: 1
Number of tenants with cognitive impairment: 13
Medication omissions: 10
Medication omissions: 7
Medication omissions: 5
Medication omissions: 4
Medication omissions: 5
Medication omissions: 10
Medication omissions: 5
Medication omissions: 5
Medication refusals: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Former staff who administered medications without completing approved medication manager course. | |
| Staff K | Former staff who administered medications prior to completing medication manager course. | |
| Staff L | Former staff who administered medications without completing approved medication manager course. | |
| Staff A | Staff who did not receive nurse delegation training within 30 days of employment. | |
| Staff B | Staff who did not receive nurse delegation training within 30 days of employment. | |
| Staff F | Staff who did not receive nurse delegation training within 30 days of employment. | |
| Staff G | Staff who did not receive nurse delegation training within 30 days of employment. | |
| Staff H | Staff observed administering medications and blood glucose monitoring without proper glove removal and hand hygiene. | |
| Staff D | Staff who did not complete dependent adult abuse training within six months of employment. | |
| Staff E | Staff who did not complete dependent adult abuse training within six months of employment and had a founded child abuse record without evaluation prior to employment. | |
| Staff J | Staff who transported tenants without appropriate chauffeur's license with passenger endorsement. |
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 1
Date: Nov 14, 2022
Visit Reason
The inspection was conducted as part of an investigation into Incident #104684-I involving an alleged theft reported by the family of a discharged tenant.
Complaint Details
The visit was complaint-related due to an alleged theft incident involving Tenant C1. The complaint was substantiated by the finding that no incident report was completed as required.
Findings
The program failed to follow established policies and procedures regarding the completion of incident reports related to the alleged theft of checks from a discharged tenant. An incident report was not completed despite the incident being reported and investigated.
Deficiencies (1)
Failure to follow established policy and procedure regarding completion of incident reports related to an alleged theft involving a discharged tenant.
Report Facts
Number of tenants without cognitive disorder: 2
Number of tenants with cognitive disorder: 16
Total census: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director | Interviewed regarding the incident and failure to complete an incident report |
Inspection Report
Renewal
Census: 14
Deficiencies: 6
Date: Apr 8, 2021
Visit Reason
The inspection was a recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
The inspection found multiple regulatory insufficiencies related to staff training and background checks, including failure to provide required dependent adult abuse training, incomplete criminal and abuse background checks prior to employment, failure to submit evaluations for staff with criminal histories, and deficiencies in dementia-specific education and hands-on training for staff.
Deficiencies (6)
Failed to provide the required 2 hours of dependent adult abuse training within six months of hire for 6 of 7 staff reviewed.
Failed to complete criminal, child, and dependent adult abuse background checks prior to employment for 1 of 7 staff reviewed.
Failed to submit an evaluation to the Department of Human Services for 2 of 7 staff reviewed with a criminal history.
Failed to provide eight hours of dementia-specific education and training within 30 days of employment for 6 of 7 staff reviewed.
Failed to provide eight hours of dementia-specific continuing education annually for 2 of 7 staff reviewed.
Failed to provide two hours of hands-on dementia training for 6 of 7 staff reviewed.
Report Facts
Census: 14
Staff reviewed: 7
Staff with dependent adult abuse training deficiency: 6
Staff with missing background checks: 1
Staff with missing DHS evaluation: 2
Staff with dementia training deficiency within 30 days: 6
Staff with missing annual dementia continuing education: 2
Staff with missing hands-on dementia training: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in findings related to dependent adult abuse training, background checks, dementia training deficiencies | |
| Staff B | Named in findings related to dependent adult abuse training and dementia training deficiencies | |
| Staff C | Named in findings related to dependent adult abuse training deficiency | |
| Staff D | Named in findings related to dependent adult abuse training, missing DHS evaluation, and dementia training deficiencies | |
| Staff E | Named in findings related to dementia training deficiencies | |
| Staff F | Named in findings related to dependent adult abuse training and dementia training deficiencies | |
| Staff G | Named in findings related to dependent adult abuse training, missing DHS evaluation, and dementia training deficiencies | |
| Quality Clinical Manager | Confirmed findings during interviews on 3-30-21 |
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 3
Date: Feb 23, 2021
Visit Reason
The inspection was conducted as a complaint investigation into multiple complaints (#91579-C, #94972-C) and an incident (#95191-I), as well as an onsite infection control survey and investigation of Complaint #92892-C.
Complaint Details
The investigation was triggered by complaints #91579-C, #94972-C, and incident #95191-I. Complaint #92892-C was also investigated but no regulatory insufficiencies were found. The complaint investigation found failures in treatment adequacy, assessment completion, and service plan updates.
Findings
The program failed to adequately meet the treatment needs of one former tenant (Tenant C6) with significant wounds and ulcers, failed to complete an initial assessment for a recently admitted tenant (Tenant #2), and failed to update service plans for four tenants (C1, C6, #7, #9) as their needs changed. No regulatory insufficiencies were cited during the infection control survey or investigation of Complaint #92892-C.
Deficiencies (3)
Failed to adequately meet the treatment needs of one former tenant (Tenant C6) with multiple ulcers and wounds that worsened due to inadequate treatment and delayed physician response.
Did not complete an initial assessment on one tenant admitted within the last four months (Tenant #2).
Failed to update service plans for four tenants (C1, C6, #7, #9) to reflect changes in their condition and needs.
Report Facts
Census: 19
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 18
Ulcer sizes: 16
Ulcer sizes: 2.5
Ulcer sizes: 4
Ulcer sizes: 2
Ulcer sizes: 2.5
Number of tenants with service plan deficiencies: 4
Number of tenants reviewed for service plans: 12
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 0
Date: Oct 24, 2019
Visit Reason
Investigation into Complaint #85619-C at an Assisted Living Program for People with Dementia.
Complaint Details
Investigation into Complaint #85619-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Inspection Report
Complaint Investigation
Census: 17
Deficiencies: 0
Date: Aug 12, 2019
Visit Reason
The visit was conducted to investigate Complaint #84095-C at the Assisted Living Program for People with Dementia.
Complaint Details
Complaint #84095-C was investigated and found not substantiated as no regulatory insufficiencies were identified.
Findings
The investigation of Complaint #84095-C did not result in any regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 16
Total census: 17
Inspection Report
Renewal
Census: 17
Deficiencies: 0
Date: Apr 16, 2019
Visit Reason
The visit was a recertification inspection to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification visit for the Assisted Living Program for People with Dementia.
Report Facts
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 16
Total census: 17
Inspection Report
Plan of Correction
Census: 18
Deficiencies: 0
Date: Oct 24, 2017
Visit Reason
The inspection was conducted as a plan of correction following investigations of incidents #70770-I and #70951-I at the assisted living program.
Findings
No regulatory insufficiencies were cited during the investigations of the incidents mentioned.
Report Facts
Number of tenants without cognitive disorder: 8
Number of tenants with cognitive disorder: 10
Total Population of Program: 18
TOTAL census of Assisted Living Program: 18
Inspection Report
Renewal
Census: 21
Deficiencies: 0
Date: Apr 10, 2017
Visit Reason
Recertification conducted to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification inspection of the Assisted Living Program.
Report Facts
Number of tenants without cognitive disorder: 15
Number of tenants with cognitive disorder: 6
Total population of Program at time of on-site: 21
Total census of Assisted Living Program: 21
Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 0
Date: Dec 19, 2016
Visit Reason
Investigation of Incident #63811-I at Brown Deer Place, an assisted living facility with a dementia-specific program.
Complaint Details
Investigation of Incident #63811-I found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the incident.
Report Facts
Number of tenants without cognitive disorder: 12
Number of tenants with cognitive disorder: 4
Total census of Assisted Living Program: 16
Inspection Report
Monitoring
Census: 15
Deficiencies: 2
Date: May 6, 2015
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation Report to determine compliance with certification for an Assisted Living Program at Hawthorne Inn at Windmill Pointe.
Findings
Regulatory insufficiencies were noted in the areas of program policies and procedures and service plans. Specifically, medication administration policies were not consistently followed, and service plans were not individualized to tenant needs and preferences.
Deficiencies (2)
Program policies and procedures related to medication administration, hand washing, and hand sanitation were not followed as required.
Service plans for tenants were not individualized to indicate the tenant's identified needs and preferences for assistance.
Report Facts
Number of tenants without cognitive disorder: 9
Number of tenants with cognitive disorder: 6
Total Population at time of on-site: 15
Total census of Assisted Living Program: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Author of the cover letter and contact person for the report |
| Staff A | Observed during medication pass with inconsistent hand washing and hand sanitizer use |
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 1
Date: Feb 6, 2014
Visit Reason
The inspection was conducted as a complaint/incident investigation following allegations related to tenant falls, staff duties outside scope of practice, staffing shortages, and deficiencies in service plans, food service, and record checks at Hawthorne Inn at Windmill Pointe.
Complaint Details
The complaint investigation included allegations of a tenant fall without assessment, staff performing duties outside their scope of practice, staffing shortages, and incomplete service plans. The tenant fall was found to be appropriately handled with no regulatory insufficiency. No staff were found to have performed duties outside their scope. Staffing was deemed sufficient. Some service plans were incomplete or unsigned. Food service staff lacked required training. Record checks were incomplete, leading to a civil penalty.
Findings
The investigation found regulatory insufficiencies in staffing, service plans, food service, and record checks. A tenant fall was investigated and assessed appropriately with no noted regulatory insufficiencies in that area. The program was assessed a $500 civil penalty for failure to perform required record checks.
Deficiencies (1)
Failure to perform required record checks as detailed in the report.
Report Facts
Civil penalty amount: 500
Reduced civil penalty amount: 325
Census: 20
Number of tenants without cognitive disorder: 16
Number of tenants with cognitive disorder: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Margaret Kaltefleiter | RN MS | Monitor for the complaint/incident investigation. |
| Rose Boccella | Program Coordinator | Contact person for questions regarding the report and penalty. |
| Jim Friberg | Acting Bureau Chief, Adult Services Bureau | Signed the demand letter. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 2, 2013
Visit Reason
The inspection was conducted as a final complaint/incident investigation following allegations related to staff not answering call lights or turning them off without responding, and complaints about smells on the unit.
Complaint Details
The complaint alleged that staff did not answer call lights or turned them off without answering, and that there were unpleasant smells on the unit with only a spray used. The investigation found no substantiated regulatory insufficiencies related to these allegations.
Findings
No regulatory insufficiencies were identified. Staff responded promptly to call lights, and there was no evidence of staff injuring tenants or turning off call lights without answering. No unpleasant smells or misuse of sprays were detected during the investigation.
Report Facts
Complaint/Incident Investigation Dates: Investigation conducted on July 2 and 3, 2013
Number of call light response time: 5
Number of maintenance reports reviewed: 45
Number of tenants at community meeting: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Margaret Kaltefleiter | RN MS, Monitor | Named as monitor for the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 2
Date: Dec 31, 2012
Visit Reason
The inspection was conducted as a Final Complaint/Incident Investigation and Recertification Monitoring Evaluation following a complaint that a tenant was found on the floor and subsequently diagnosed with a fractured hip.
Complaint Details
The complaint alleged a tenant was found on the floor, was responsive and in no distress, but was later diagnosed with a fractured hip after being transported to a hospital. The tenant passed away several days later. The complaint investigation included interviews with staff and review of incident reports and tenant records. The complaint was not substantiated as a regulatory insufficiency.
Findings
The investigation found no regulatory insufficiencies related to the incident of the tenant found on the floor. However, regulatory insufficiencies were noted regarding the primary van driver's license validity and staff criminal history background checks.
Deficiencies (2)
The primary van driver did not have a valid and appropriate Iowa driver's license or commercial driver's license as required by law.
Staff #2 and Staff #4 began work prior to completion of required criminal history, dependent adult abuse, and child abuse background checks.
Report Facts
Tenant count: 22
Tenants without cognitive disorder: 17
Tenants with cognitive disorder: 5
Complaint/Incident Intake Number: 41495
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anne Stramel | Estate Manager | Named as Estate Manager involved in the complaint investigation and incident |
| Margaret Kaltefleiter | RN MS | Monitor of the complaint/incident investigation |
| Rose Boccella | Program Coordinator | Signed letter transmitting the final complaint/incident investigation report |
Inspection Report
Monitoring
Census: 19
Deficiencies: 1
Date: May 23, 2011
Visit Reason
An on-site monitoring evaluation was conducted at Hawthorne Inn at Windmill Pointe to review the Plan of Correction and assess compliance with regulatory requirements.
Findings
The program did not receive any regulatory insufficiencies during this certification period. However, a regulatory insufficiency was noted regarding the inconsistent completion of 90 day health reviews for tenants.
Deficiencies (1)
A 90 day health review was not consistently completed every 90 days for tenants.
Report Facts
Current number of tenants with dementia: 7
Current number of tenants without cognitive disorder: 12
Total population: 19
Community meeting attendees: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Conducted the monitoring evaluation |
| Margaret Kaltefleiter | Monitor, RN MS | Conducted the monitoring evaluation |
| Anne Stramel | Estate Manager | Facility manager named in the report |
Inspection Report
Monitoring
Census: 20
Deficiencies: 3
Date: Jan 27, 2009
Visit Reason
An on-site monitoring evaluation was conducted at Hawthorne Inn to review the Plan of Correction in response to the Recertification Monitoring Evaluation Report and to assess compliance with regulatory requirements.
Findings
The program had several regulatory insufficiencies including inconsistent medication administration documentation, incomplete nurse review documentation, and lack of a first aid kit in the transportation vehicle. Tenant satisfaction was generally positive with no substantiated regulatory insufficiencies during the certification period.
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 provide written documentation of nursing activities showing the time.
The program did not consistently provide a first aid kit in the transportation vehicle.
Report Facts
Tenants with dementia or cognitive disorder: 5
Tenants without cognitive disorder: 15
Total population: 20
Community meeting attendees: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Conducted the on-site monitoring evaluation |
Inspection Report
Monitoring
Census: 20
Deficiencies: 8
Date: Apr 12, 2005
Visit Reason
An on-site monitoring evaluation revisit was conducted at Hawthorn Inn on April 12, 2005, as part of a re-certification monitoring evaluation with conditional certification.
Findings
The program had received multiple insufficiencies related to occupancy agreements, tenant evaluations, service plans, medications, staffing, and record checks from a prior January monitoring visit. Several regulatory insufficiencies were noted, including failure to assess cognitive status of some tenants, incomplete service plans, medication order documentation issues, lack of caregiver skills documentation, and failure to obtain criminal and adult abuse history checks prior to hire. Plans of correction were outlined for these deficiencies.
Deficiencies (8)
Three insufficiencies related to occupancy agreements from January monitoring visit.
Two insufficiencies related to evaluation of tenants, including failure to assess cognitive, functional, or health status of three tenants and failure to use Global Deterioration Scale within 30 days of admission.
One insufficiency related to tenant service notes documentation; no regulatory insufficiency noted.
Two insufficiencies related to service plans, including incomplete plans and lack of signatures or documentation of tenant/legal representative participation.
Two insufficiencies related to medications, including failure to note physician orders with signature, date, and time.
Insufficiency due to RN not conducting 90-day medication reviews during January visit; no regulatory insufficiency noted.
Two insufficiencies related to staffing, including failure to document assessment or monitoring of caregiver skills.
Insufficiency related to failure to obtain criminal and adult abuse history checks prior to hire.
Report Facts
Current number of tenants without cognitive disorder: 15
Current number of tenants with cognitive disorder: 5
Total General Population: 20
Insufficiencies related to occupancy agreements: 3
Insufficiencies related to evaluation of tenants: 2
Insufficiencies related to service plans: 2
Insufficiencies related to medications: 2
Insufficiencies related to staffing: 2
Inspection Report
Monitoring
Census: 22
Deficiencies: 8
Date: Jan 27, 2005
Visit Reason
The visit was a re-certification monitoring evaluation conducted to assess compliance with Iowa assisted living program regulations and to evaluate tenant care and program operations.
Complaint Details
No substantiated complaints during this certification period.
Findings
The monitoring evaluation identified multiple regulatory insufficiencies including improper signing of occupancy agreements, inadequate tenant evaluations by non-professionals, incomplete tenant documentation, failure to update service plans timely, medication administration errors, lack of proper nurse reviews, insufficient staff training documentation, and missing employee dependent adult abuse record checks.
Deficiencies (8)
Occupancy agreements were not all signed prior to occupancy, and some were signed by persons without documented legal authority.
Tenant evaluations were performed by a non-health professional and were incomplete or not conducted timely.
Tenant files lacked documentation of health professionals' orders, treatments, therapy, medication, and service notes.
Service plans were not developed or updated by qualified professionals and lacked tenant or legal representative consultation.
Medication administration was performed by unlicensed staff with multiple errors and improper techniques observed.
Registered nurse did not conduct required 90-day medication and health status reviews or document interventions.
Staff training documentation was sporadic and incomplete; no staffing plan was maintained.
Employee files lacked documentation of dependent adult abuse record checks prior to hire.
Report Facts
Current number of tenants without cognitive disorder: 15
Current number of tenants with cognitive disorder: 7
Total Population: 22
Number of tenant files reviewed: 8
Number of personnel files reviewed: 6
Viewing
Loading inspection reports...
