Inspection Report Summary
The most recent inspection on August 20, 2025, identified deficiencies related to food safety, tenant care following a fall, and notification procedures. Earlier inspections showed a pattern of issues involving medication administration, tenant care, documentation, and staff training, with repeated citations for incomplete service plans and failure to follow policies. Complaint investigations often substantiated concerns about inadequate care, medication errors, and incident reporting, including a notable injury due to staff not using a required gait belt. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history reflects ongoing challenges with compliance, with deficiencies continuing in recent years despite some corrective efforts.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
6.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
51 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 4
Date: Aug 20, 2025
Visit Reason
The inspection was conducted related to Complaint #128415-C and Incident #129285-I involving regulatory insufficiencies in food safety, tenant care, and notification procedures.
Complaint Details
The visit was complaint-related involving Complaint #128415-C and Incident #129285-I. Tenant #1's fall and injury were substantiated with findings of inadequate care and failure to follow service plans.
Findings
The program failed to follow established policies related to food safety and sanitation, including unlabeled foods and incomplete temperature logs. Additionally, the program failed to provide adequate care to Tenant #1, who sustained a pelvic fracture after a fall due to staff not using a required gait belt. The program also failed to notify the Department within 24 hours of the major injury. Furthermore, several dietary staff lacked proper orientation and annual training on food safety.
Deficiencies (4)
Failed to follow established policy and procedure related to food safety and sanitation, including unlabeled foods and incomplete temperature logs.
Failed to provide adequate care to Tenant #1 who fell and sustained a pelvic fracture due to staff not using a gait belt as required by the service plan.
Failed to notify the Department within 24 hours or next business day of an accident causing major injury to Tenant #1.
Failed to provide orientation on sanitation and safe food handling prior to handling food and annual in-service training on food protection for 4 of 7 dietary staff.
Report Facts
Total census: 51
Number of tenants without cognitive impairment: 32
Number of tenants with cognitive impairment: 19
Incident date: Jun 4, 2025
Report date to Department: Jun 7, 2025
Number of dietary staff lacking proper training: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Staff who failed to use gait belt with Tenant #1 leading to fall and injury; received counseling and re-education | |
| Staff B | Staff who provided interview regarding fall incident involving Tenant #1 | |
| Staff C | Staff who provided interview regarding fall incident involving Tenant #1 | |
| Regional Nurse Specialist | Completed electronic report of incident and explained delay in reporting due to Former Director's departure | |
| Culinary Coordinator | Provided information on food safety training and staff responsibilities | |
| Former Director | Conducted investigation of Tenant #1 fall and confirmed staff failure to use gait belt |
Inspection Report
Plan of Correction
Census: 45
Deficiencies: 3
Date: Apr 1, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to Incident #125272-I and Complaint #124843-C at Emery Place, an assisted living program for people with dementia.
Complaint Details
The visit was related to the investigation of Complaint #124843-C and Incident #125272-I. No regulatory insufficiencies were identified related to Incident #125272-I. Deficiencies were cited related to Complaint #124843-C.
Findings
The program failed to follow established policies and procedures related to administration of PRN medications for one tenant, failed to complete required evaluations for one tenant, and failed to update service plans as needed for one tenant. The Plan of Correction is attached to address these deficiencies.
Deficiencies (3)
Program failed to follow established policy and procedure related to administration of PRN medications for Tenant #1.
Program failed to complete evaluations as needed for Tenant #1.
Program failed to update service plans as needed for Tenant #1.
Report Facts
Number of tenants without cognitive impairment: 29
Number of tenants with cognitive impairment: 16
Total census: 45
Number of tenants reviewed for evaluations and service plans: 5
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 10
Date: Oct 1, 2024
Visit Reason
The inspection was conducted related to the investigation of Complaints #117848-C and #122653-C, the recertification visit to determine compliance with certification of a Dedicated Dementia Specific Assisted Living Program, and the revisit of FC 10179.
Complaint Details
The visit was complaint-related involving Complaints #117848-C and #122653-C. The investigation found multiple regulatory insufficiencies related to tenant care, medication administration, documentation, and transfer procedures.
Findings
The program failed to include required information regarding involuntary transfer procedures and internal appeals in the occupancy agreement, failed to follow established policies related to medications and incident reports, failed to provide adequate care and services, failed to administer medications as ordered, and failed to maintain proper documentation and service plans. Multiple tenants had medication errors, refusals of care, and incomplete evaluations or service plans.
Deficiencies (10)
Occupancy agreement did not include required information on involuntary transfer procedures and internal appeals.
Program failed to follow established policies and procedures related to medications and incident reports.
Program failed to provide adequate and appropriate care, treatment, and services to tenants.
Medications and treatments were not administered as prescribed by the tenant's physician or advanced registered nurse practitioner.
Certified and noncertified staff did not receive adequate training regarding service plan tasks including wound care, pain management, rehabilitation needs, and hospice care.
Program failed to complete evaluations as needed with significant change.
Program failed to notify tenant's primary care provider of involuntary transfer.
Program failed to maintain proper tenant documentation including nurse's notes by exception.
Service plans were not developed or updated as required based on evaluations and significant changes.
Service plans were not signed and dated by all parties within 30 days of occupancy.
Report Facts
Total census: 48
Tenants without cognitive impairment: 32
Tenants with cognitive impairment: 16
Tenants reviewed for medication and incident reports: 9
Tenants with medication errors: 5
Tenants reviewed for care adequacy: 6
Tenants reviewed for evaluations: 6
Tenants reviewed for documentation: 3
Tenants reviewed for service plans: 6
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 18
Date: Nov 15, 2023
Visit Reason
The inspection was conducted due to investigations of multiple incidents and complaints related to the assisted living program.
Complaint Details
The visit was complaint-related triggered by multiple incidents and complaints including medication errors, inadequate care, and staffing concerns.
Findings
The Program failed to implement established policies and procedures related to incident reports, visual checks, medication administration, tenant rights, adequate and appropriate care, medication management, staffing, nurse delegation, service plans, nurse reviews, and activities. Multiple tenants experienced medication errors, inadequate care, insufficient staffing, and lack of proper documentation and evaluations.
Deficiencies (18)
Failure to implement policies and procedures related to incident reports, visual checks, and medication administration.
Failure to ensure tenants were treated with consideration, respect, and full recognition of personal dignity and autonomy.
Failure to provide adequate and appropriate care and services to tenants, including wound care, transfers, and medication administration.
Failure to administer medications by trained staff with proper certification prior to administration.
Failure to administer medications as prescribed, including medication refusals not properly handled and medications not available.
Failure to maintain sufficient staffing to meet tenants' needs, resulting in delayed care and medication administration.
Failure to provide nurse delegated training within 30 days of employment for some staff.
Failure to ensure staff were competent to meet tenants' needs including training on service plan tasks such as continuous glucometer use and colostomy care.
Failure to ensure staff documented occurrences that differed from tenants' normal health, functional, and cognitive status.
Failure to provide appropriate activities reflecting individual tenant differences in the memory care units.
Failure to provide 30-day written notice to tenants regarding changes in medication services and fees.
Failure to complete evaluations as needed with significant change for multiple tenants.
Failure to update service plans as needed and ensure they reflect tenants' service needs.
Failure to obtain signatures from tenants or legal representatives on updated service plans after significant changes.
Failure to complete nurse reviews as needed related to changes in tenants' health status.
Failure to discharge tenants requiring routine two-person assistance with transfers, contrary to admission/retention criteria.
Failure to notify tenant or legal representative of need for involuntary transfer, reason for transfer, and ombudsman contact information.
Failure to document nurse's notes by exception for significant changes in tenant condition.
Report Facts
Total census: 53
Medication refusal dates: 5
Medication manager training delay: 30
Staff on shift: 3
Pendant response delay: 83
Medication administration delay: 120
Activities scheduled: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Manager | Named in medication error and training deficiency findings |
| Staff K | Medication Manager | Named in medication training delay and staffing findings |
| Staff B | Named in sleeping on duty and fall incident findings | |
| Staff R | Named in sleeping on duty findings | |
| Staff S | Named in sleeping on duty findings | |
| Healthcare Coordinator | Named in multiple findings related to medication refusals, evaluations, and transfers | |
| Executive Director | Named in staffing and activities findings | |
| Hospice Nurse #1 | Named in transfer and care findings for Tenant #10 | |
| Hospice Nurse #2 | Named in transfer and care findings for Tenant #7 and Tenant #9 |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 0
Date: Jan 19, 2023
Visit Reason
The inspection was conducted to investigate complaints #105704-C, #107942-C, and #107944-C at the assisted living facility Emery Place.
Complaint Details
Investigation of Complaints #105704-C, #107942-C, and #107944-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints.
Report Facts
Number of tenants without cognitive impairment: 39
Number of tenants with cognitive impairment: 13
Total census: 52
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 7
Date: Jan 19, 2022
Visit Reason
The investigation of Complaints #95611-C, #95612-C, #95613-C and #98302-C and the recertification visit were conducted to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Complaint Details
Complaints #95611-C, #95612-C, #95613-C and #98302-C were investigated as part of this visit.
Findings
The inspection identified regulatory insufficiencies related to tenant rights, including failure to treat a tenant with dignity and respect, failure to provide adequate care and treatment resulting in injury, and failure to administer medications as prescribed. Additional deficiencies were found in nurse delegation, documentation, and service plans.
Deficiencies (7)
Program failed to treat a tenant with consideration, respect, and full recognition of personal dignity and autonomy related to pharmacy choice and medication administration.
Program failed to provide adequate and appropriate care, treatment and services to a tenant who fell, sustained injury, and was sent out for evaluation.
Program failed to administer medications and complete treatments as prescribed for multiple tenants.
Program failed to ensure staff received nurse delegation training within 30 days of employment.
Program failed to document nurse's notes by exception for multiple tenants.
Program failed to update service plans as needed and ensure signatures of involved parties.
Program failed to complete nurse reviews when significant changes in tenant condition occurred.
Report Facts
Number of tenants in census: 54
Number of tenants without cognitive disorder in general population: 28
Number of tenants with cognitive disorder in general population: 1
Number of tenants without cognitive disorder in memory care unit: 7
Number of tenants with cognitive disorder in memory care unit: 25
Number of tenants reviewed for medication administration deficiency: 7
Number of tenants reviewed for documentation deficiency: 7
Number of tenants reviewed for nurse review deficiency: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Crosser | Director | Named in Plan of Correction signature |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 0
Date: Dec 6, 2018
Visit Reason
The inspection was conducted as an investigation into Complaint #79568-C at the assisted living facility.
Complaint Details
Investigation into Complaint #79568-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder in general population: 31
Number of tenants with cognitive disorder in general population: 0
Number of tenants without cognitive disorder in Memory Care Unit: 6
Number of tenants with cognitive disorder in Memory Care Unit: 19
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 0
Date: Oct 11, 2018
Visit Reason
The inspection was conducted as an investigation into Complaint #77745-C at Emery Place, an assisted living program for people with dementia.
Complaint Details
Investigation into Complaint #77745-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder in general population: 31
Number of tenants with cognitive disorder in general population: 0
Number of tenants without cognitive disorder in memory care unit: 6
Number of tenants with cognitive disorder in memory care unit: 19
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Date: Jun 25, 2018
Visit Reason
The inspection was conducted as a complaint investigation related to medication administration deficiencies at Emery Place, an assisted living program for people with dementia.
Complaint Details
Complaint Intake #: 76246-C. The investigation found the medication administration failure substantiated based on interviews and record reviews.
Findings
The program failed to administer medications as prescribed by the tenant's physician for one of four tenants reviewed, specifically Tenant #1 who did not receive prescribed Miralax for constipation for eight days, resulting in adverse health effects.
Deficiencies (1)
Program failed to administer medications according to doctor's orders for 1 of 4 tenants reviewed (Tenant #1).
Report Facts
Number of tenants without cognitive disorder in General Population Unit: 25
Number of tenants with cognitive disorder in General Population Unit: 0
Number of tenants without cognitive disorder in Memory Care Unit: 6
Number of tenants with cognitive disorder in Memory Care Unit: 21
Total Census of Assisted Living Program for People with Dementia: 52
Number of tenants reviewed for medication administration: 4
Investigation date range: 6
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 2
Date: Feb 20, 2018
Visit Reason
Complaint #74142-C was investigated regarding program policies and procedures for incident reports, including timely completion and appropriate follow-up to incidents.
Complaint Details
Complaint #74142-C was investigated and substantiated with cited regulatory insufficiencies related to incident reporting and notification.
Findings
The program failed to follow policy and procedure for incident reports, affecting 1 of 4 tenants reviewed. Incident reports were not completed timely, and staff failed to notify the department of an attempted suicide within required timeframes.
Deficiencies (2)
Program failed to follow policy and procedure for completion of incident reports, including timely completion and appropriate follow up to incidents.
Program failed to report an attempted suicide without injury to the Department within 24 hours or the next business day.
Report Facts
Number of tenants without cognitive disorder in general population: 29
Number of tenants with cognitive disorder in general population: 0
Number of tenants without cognitive disorder in memory care unit: 4
Number of tenants with cognitive disorder in memory care unit: 17
Total census of assisted living program for people with dementia: 50
Tenants reviewed: 4
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 2
Date: Dec 19, 2017
Visit Reason
The inspection was conducted as a result of the investigation of Complaint #71245-C regarding regulatory insufficiencies at Emery Place.
Complaint Details
Complaint #71245-C was investigated, and regulatory insufficiencies were cited related to incident reporting and documentation failures.
Findings
The program failed to follow policies and procedures for incident reports, specifically for Tenant #2, including missing incident reports for aggressive behavior and falls. Documentation and nurses' notes were incomplete or not timely for multiple tenants reviewed.
Deficiencies (2)
Program failed to follow policy and procedure for completion of incident reports for 1 of 4 tenants reviewed (Tenant #2).
Failed to document nurses' notes written by exception for 3 of 4 tenants reviewed (Tenants #2, #3, and #4).
Report Facts
Number of tenants without cognitive disorder in general population: 28
Number of tenants with cognitive disorder in general population: 0
Number of tenants without cognitive disorder in memory care unit: 5
Number of tenants with cognitive disorder in memory care unit: 19
Total census of Assisted Living Program for People with Dementia: 52
Inspection Report
Renewal
Census: 52
Deficiencies: 0
Date: Aug 14, 2017
Visit Reason
The visit was a recertification inspection to determine compliance with certification for an Assisted Living Program.
Complaint Details
Investigation of Complaint #68660-C was completed and no regulatory insufficiencies were identified related to the complaint.
Findings
No regulatory insufficiencies were cited during the recertification visit. An investigation of Complaint #68660-C was completed with no regulatory insufficiencies identified related to the complaint.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 28
Number of tenants with cognitive disorder in General Population Program: 0
Total population of General Population Program: 28
Number of tenants without cognitive disorder in Dementia-Specific Program Unit #1: 0
Number of tenants with cognitive disorder in Dementia-Specific Program Unit #1: 10
Total population of Dementia-Specific Program Unit #1: 10
Number of tenants without cognitive disorder in Dementia-Specific Program Unit #2: 6
Number of tenants with cognitive disorder in Dementia-Specific Program Unit #2: 8
Total population of Dementia-Specific Program Unit #2: 14
Total census of Assisted Living Program: 52
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 1
Date: Apr 13, 2016
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #58218-C concerning staffing, level of care, and service plans at Emery Place.
Complaint Details
The complaint investigation addressed allegations of staffing and level of care, both found unsubstantiated. A regulatory insufficiency was substantiated related to service plans.
Findings
No regulatory insufficiencies were found related to staffing or level of care, but a regulatory insufficiency was identified in the area of service plans due to failure to develop individualized service plans reflecting tenants' identified needs and preferences.
Deficiencies (1)
Failure to develop individualized service plans that indicate tenants' identified needs and preferences for assistance, specifically for two tenants who lacked service plans reflecting their needs.
Report Facts
Number of tenants without cognitive disorder: 24
Number of tenants with cognitive disorder: 12
Total census of Assisted Living Program: 36
Date survey completed: Apr 13, 2016
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 3
Date: Jan 7, 2016
Visit Reason
The inspection was conducted as a complaint/incident investigation following complaints #56810-C and #57082-C regarding staffing, medications, admission/retention of tenants, and service plans at Emery Place.
Complaint Details
The complaint investigation was based on tenant files, incident reports, medication error reports, staff and tenant interviews, management interviews, and policy reviews. Staffing allegations were not substantiated. Medication, admission/retention, and service plan deficiencies were found.
Findings
The investigation found no substantiated staffing issues but identified regulatory insufficiencies related to medication administration, admission/retention criteria, and individualized service plans. The program was required to submit a Plan of Correction to address these deficiencies.
Deficiencies (3)
The program did not administer medications per physician orders and documentation was incomplete or inaccurate for multiple tenants.
The program failed to discharge a tenant who exceeded the criteria for admission and retention.
Service plans were not individualized to reflect tenants' needs and preferences for assistance.
Report Facts
Census: 35
Number of tenants without cognitive disorder: 24
Number of tenants with cognitive disorder: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator, Adult Services Bureau | Author of the cover letter and contact for questions |
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 2
Date: Aug 6, 2015
Visit Reason
The inspection was conducted as a complaint intake investigation following allegations related to record checks and structural requirements at Emery Place, an assisted living program.
Complaint Details
Complaint investigation intake #54461-I was substantiated with findings of regulatory insufficiencies in record checks and structural requirements. The tenant eloped from a locked dementia unit through an unlocked courtyard gate.
Findings
The report identified regulatory insufficiencies in record checks and structural requirements, including incomplete criminal, dependent adult abuse, and child abuse record checks prior to hiring staff, and failure to maintain a locked courtyard gate leading to a tenant elopement.
Deficiencies (2)
Record checks were not completed appropriately prior to hiring Staff A and Staff B, including criminal history, dependent adult abuse, and child abuse checks.
Structural requirements were not met as the courtyard gate was not consistently locked, resulting in a tenant elopement.
Report Facts
Census: 23
Civil penalty amount: 1000
Reduced civil penalty amount: 650
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in record check deficiency; hired without completed background checks | |
| Staff B | Named in record check deficiency; hired without completed background checks | |
| Jim Friberg | Acting Bureau Chief, Adult Services Bureau | Signed the demand letter |
| Rose Boccella | Program Coordinator | Contact person for appeal and informal conference |
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