Inspection Report Summary
The most recent inspection on October 24, 2024, found no deficiencies during the complaint investigation and recertification visit. Earlier inspections showed a pattern of deficiencies primarily related to documentation and the development of individualized service plans reflecting tenant needs, with some issues noted in staff training and maintenance of the physical environment. Complaint investigations included one substantiated case in 2012 involving retention of a tenant with unsafe behaviors, but most complaints were unsubstantiated or resolved without citations. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows improvement over time, with the most recent inspections free of deficiencies after earlier citations.
Deficiencies (last 11 years)
Deficiencies (over 11 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
70% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
19 residents
Based on a October 2024 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 0
Date: Oct 24, 2024
Visit Reason
The inspection was conducted to investigate Complaint #122058-C and to perform a recertification visit to determine compliance with certification of an Assisted Living Program.
Complaint Details
Complaint #122058-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation or the recertification visit.
Report Facts
Number of tenants without cognitive impairment: 18
Number of tenants with cognitive impairment: 1
Total census: 19
Inspection Report
Renewal
Census: 16
Deficiencies: 2
Date: Aug 31, 2021
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification requirements for an Assisted Living Program.
Findings
The inspection found no regulatory insufficiencies during the onsite infection control survey. However, deficiencies were cited related to documentation of tenant health-related care and individualized service plans reflecting tenant needs and preferences.
Deficiencies (2)
Failure to document nurses' notes by exception for a tenant's health-related care.
Failure to develop individualized service plans reflecting tenants' identified needs and preferences for assistance.
Report Facts
Number of tenants without cognitive disorder: 16
Number of tenants with cognitive disorder: 0
Total census of Assisted Living Program: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager | Interviewed and confirmed findings related to documentation and service plans; responsible for reviewing regulations and educating staff. | |
| Staff A | Interviewed regarding tenant bathing assistance and refusals. |
Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 1
Date: Jan 28, 2020
Visit Reason
The investigation was conducted as a result of Complaint #87102-C which resulted in a regulatory insufficiency.
Complaint Details
Investigation of Complaint #87102-C resulted in a regulatory insufficiency.
Findings
The program failed to develop individualized service plans reflecting the identified needs of tenants, as evidenced by deficiencies in service plans for tenants #2, #3, and #4. Multiple incidents of falls and inadequate documentation of interventions and treatments were noted.
Deficiencies (1)
Failure to develop service plans that reflected the identified needs of tenants, including history of falls, interventions, and treatment plans.
Report Facts
Number of tenants without cognitive disorder: 16
Number of tenants with cognitive disorder: 0
Total census of Assisted Living Program: 16
Number of tenants reviewed for service plan deficiencies: 4
Number of falls/incidents documented for Tenant #3: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Toni Allen | Manager | Signed as Laboratory Director's or Provider/Supplier Representative on the report. |
Inspection Report
Renewal
Census: 18
Deficiencies: 0
Date: Jul 18, 2019
Visit Reason
The visit was a recertification inspection conducted to determine compliance with certification of an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification visit for the Assisted Living Program.
Inspection Report
Renewal
Census: 20
Deficiencies: 0
Date: Jul 10, 2017
Visit Reason
Recertification visit conducted to determine compliance with certification of an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification visit.
Report Facts
Number of tenants without cognitive disorder: 20
Number of tenants with cognitive disorder: 0
Total Population of Program at time of on-site: 20
TOTAL census of Assisted Living Program: 20
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 1
Date: Nov 2, 2016
Visit Reason
An investigation of Complaint #62403-C was completed to assess regulatory compliance related to the complaint.
Complaint Details
Complaint #62403-C was investigated and regulatory insufficiency was identified related to the complaint.
Findings
The facility failed to develop individualized service plans reflecting tenants' identified needs and preferences, specifically for Tenant #2. Issues included non-compliance with diabetic diet, blood sugar fluctuations, insulin administration, and behavior management related to safety concerns.
Deficiencies (1)
Failure to develop individualized service plans reflecting tenant's identified needs and preferences for assistance.
Report Facts
Number of tenants without cognitive disorder: 18
Number of tenants with cognitive disorder: 0
Total population at time of on-site: 18
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 0
Date: Jul 6, 2015
Visit Reason
The inspection was conducted as a Final Complaint & Recertification Monitoring Evaluation in response to Complaint #53093-C regarding food service at Cedar Vale Assisted Living Program.
Complaint Details
Complaint #53093-C alleged issues with food service. The findings were unsubstantiated after interviews with 12 tenants, staff, and review of food temperature logs. No ongoing concerns were noted and dietary staff properly documented food temperature checks.
Findings
The complaint was found to be unsubstantiated with no regulatory insufficiencies cited during the evaluation. Observations, tenant interviews, and program documentation review revealed no ongoing dietary concerns or consistent issues with food service.
Report Facts
Number of tenants without cognitive disorder: 17
Number of tenants with cognitive disorder: 1
Total population at time of on-site: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Signed letter regarding certification and complaint evaluation |
| Tonia Olsen | Director | Named as facility director in letter |
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 0
Date: Dec 10, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation following an allegation that the assisted living program admitted a tenant who required a higher level of care.
Complaint Details
The complaint alleged that the program admitted a tenant requiring a higher level of care. The investigation reviewed tenant files and conducted interviews, concluding that no tenants exceeded the level of care and no regulatory insufficiencies were noted.
Findings
No regulatory insufficiencies were identified during the investigation. The program was found to have adequate staffing and appropriate care for tenants, with no tenants exceeding the level of care for assisted living.
Report Facts
Number of tenants without cognitive disorder: 17
Number of tenants with cognitive disorder: 2
Total census of Assisted Living Program: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Margaret Kaltefleiter | RN MS | Monitor for the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 2
Date: Sep 26, 2013
Visit Reason
The inspection was conducted in response to a complaint alleging issues such as garbage not being removed from apartments, lack of automatic doors for tenant safety, improper dryer venting, and unsafe patio furniture.
Complaint Details
Complaint/Incident Intake #45466-C involved allegations of garbage not being removed, lack of automatic doors, improper dryer venting, and unsafe patio furniture. The complaint was investigated with observations and interviews conducted. No regulatory insufficiencies were noted for garbage removal, automatic doors, or dryer venting. Patio furniture was found unsafe and in disrepair.
Findings
The investigation found no regulatory insufficiencies related to garbage removal, automatic doors, or dryer venting, though concerns about the dryer venting safety were raised and addressed. Patio furniture was found to be in disrepair with broken and loose straps, and some furniture was removed during the visit. The buildings and grounds were noted to require maintenance to be clean, safe, and sanitary.
Deficiencies (2)
Two patio chairs, a patio sofa, and a lawn chair were in a state of disrepair with broken and loose straps; some furniture was removed during the onsite visit.
The buildings and grounds shall be well-maintained, clean, safe and sanitary (IAC r. 481-69.35(1)(b)).
Report Facts
Number of tenants without cognitive disorder: 18
Number of tenants with cognitive disorder: 3
Total Population of Program at time of on-site: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori Miner | RN BSN | Monitor conducting the complaint/incident investigation |
Inspection Report
Monitoring
Census: 18
Deficiencies: 5
Date: Apr 1, 2013
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation to review the Plan of Correction submitted in response to a Preliminary Recertification Monitoring Evaluation Report and to verify compliance with regulatory requirements for the assisted living program.
Findings
The program had no regulatory insufficiencies during this certification period. Tenant satisfaction was generally positive, and the program environment was clean and safe. However, deficiencies were noted in dementia-specific education for program personnel, with several staff lacking required documentation of dementia-specific training.
Deficiencies (5)
Staff #2's file lacked documentation of any dementia-specific education.
Staff #3's file lacked documentation of any dementia-specific education.
Staff #4 had not been employed for 30 days at the time of the monitoring visit, so dementia-specific education documentation was not applicable.
Staff #5's file lacked documentation of any dementia-specific education.
Staff #6's file lacked documentation of any dementia-specific education.
Report Facts
Number of tenants without cognitive disorder: 13
Number of tenants with cognitive disorder: 5
Total Population of Program at time of on-site: 18
Tenants attending community meeting: 16
Family members attending community meeting: 1
Hours of dementia-specific education documented for Staff #1: 6.5
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 1
Date: Nov 2, 2012
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding allegations that a tenant had a loaded gun, urinated in inappropriate places, used profane language, and threatened other tenants.
Complaint Details
The complaint was substantiated. It involved allegations of a tenant possessing a loaded gun, urinating in inappropriate places, using profane language, and threatening other tenants. The tenant was found to have a history of suicidal ideation, verbal abuse, refusal to comply with medication and care, and unsafe behaviors. The program did not provide a written discharge notice despite immediate termination of residence.
Findings
The investigation found that Tenant #1 had multiple behavioral and health issues including urinary incontinence, verbal aggression, possession of a firearm despite program rules, and refusal to comply with care and program policies. The tenant was deemed dangerous to self and others, leading to a regulatory insufficiency due to the program's inability to safely retain the tenant.
Deficiencies (1)
A program shall not knowingly admit or retain a tenant who is dangerous to self or others, or displays unmanageable behaviors including verbal abuse or aggression.
Report Facts
Number of tenants without cognitive disorder: 14
Number of tenants with cognitive disorder: 5
Total Population at time of on-site: 19
Date of Complaint/Incident Investigation: Nov 2, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tonia Olsen | Manager | Named as manager providing information and involved in tenant management |
| Lori Miner | RN BSN | Monitor during complaint/incident investigation |
| Joyce Kix | RN | Monitor during complaint/incident investigation |
Inspection Report
Monitoring
Census: 15
Deficiencies: 2
Date: Jun 9, 2011
Visit Reason
An on-site monitoring evaluation was conducted at Cedar Vale Assisted Living to review the Plan of Correction in response to a Preliminary Recertification Monitoring Evaluation Report and to assess compliance with regulatory requirements.
Findings
The program had no regulatory insufficiencies during this certification period. Observations included medication administration and dependent adult abuse training, with some noted regulatory insufficiencies related to medication administration by unlicensed personnel and incomplete approval of abuse training programs.
Deficiencies (2)
The administration of medications shall be provided by a registered nurse, licensed practical nurse or advanced registered nurse practitioner or by unlicensed personnel in accordance with nurse delegation requirements.
The person may complete the initial or additional dependent adult abuse training requirements only through approved programs; the current self-study program had not been approved by the state's abuse education review panel.
Report Facts
Current number of tenants without cognitive disorder: 14
Current number of tenants with cognitive disorder: 1
Total Population: 15
Tenant meeting attendance: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tonia Olsen | Manager | Manager of Cedar Vale Assisted Living named in report |
| Maribeth Freland | RN | Monitor conducting the evaluation |
Inspection Report
Monitoring
Census: 19
Deficiencies: 0
Date: Apr 19, 2007
Visit Reason
An on-site monitoring evaluation was conducted as part of the recertification monitoring of Cedar Vale Assisted Living to assess compliance with regulatory requirements.
Complaint Details
There were no substantiated complaints during this certification period.
Findings
The evaluation found no regulatory insufficiencies during the on-site visit. Tenant satisfaction was positive, with tenants reporting good housekeeping, helpful staff, good food, enjoyable activities, and feeling safe.
Report Facts
Current number of tenants without cognitive disorder: 19
Current number of tenants with cognitive disorder: 0
Total Population: 19
Tenant meeting attendance: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the on-site monitoring evaluation |
| Tonia Olsen | Administrator | Administrator of Cedar Vale Assisted Living |
Viewing
Loading inspection reports...
