Inspection Report Summary
The most recent inspection on May 21, 2025, cited deficiencies related to building maintenance, including roof leaks and damaged ceiling tiles in the dining area. Earlier inspections showed a pattern of deficiencies involving medication administration, service plan updates, tenant evaluations, and policy compliance, with issues such as failure to administer medications as prescribed, incomplete background checks, and untimely incident notifications. Complaint investigations were mostly substantiated when deficiencies were found, particularly concerning medication errors and service plan inadequacies, while some complaints were unsubstantiated. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The inspection history indicates ongoing challenges with building upkeep and regulatory compliance, with some corrective actions noted but persistent maintenance issues remaining unresolved.
Deficiencies (last 13 years)
Deficiencies (over 13 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
20 residents
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 1
Date: May 21, 2025
Visit Reason
The inspection was conducted as an investigation of Complaints 125771-C and 125821-C regarding the condition and maintenance of the assisted living facility.
Complaint Details
The investigation was triggered by complaints 125771-C and 125821-C. The roof leaks and heating system issues were confirmed through tenant and staff interviews and observations. The roof leak issue has persisted for at least five years, and repairs have not been completed despite bids and tar application.
Findings
The facility failed to consistently maintain the building, with issues including roof leaks causing water to drip into the dining area, stained and damaged ceiling tiles, and unresolved heating system problems. These deficiencies potentially affected all 20 tenants.
Deficiencies (1)
The buildings and grounds were not well-maintained, clean, safe, and sanitary, evidenced by roof leaks and damaged ceiling tiles in the dining area.
Report Facts
Number of tenants without cognitive impairment: 19
Number of tenants with cognitive impairment: 1
Total census: 20
Years roof leak issue persisted: 5
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 1
Date: Dec 23, 2024
Visit Reason
The inspection was conducted to investigate complaints 125296-C, 125298-C, and incident 125301-I regarding Heritage Court Assisted Living.
Complaint Details
The investigation involved complaints 125296-C, 125298-C, and incident 125301-I. No insufficiencies were found for complaint 121969-C. The cited deficiency was related to door alarm policy noncompliance. The facility asserted substantial compliance with corrective actions by 2/19/2025.
Findings
No regulatory insufficiencies were cited during complaint 121969-C. One regulatory insufficiency was cited for failure to follow program policies and procedures related to door alarms and staff response. The facility was found to be in substantial compliance as of 2/19/2025 after corrective actions.
Deficiencies (1)
Program failed to follow policy and procedure for door alarms regarding 1 of 1 tenants reviewed, including turning off the alarm prior to 6:00 a.m.
Report Facts
Number of tenants without cognitive impairment: 20
Number of tenants with cognitive impairment: 2
Total census: 22
Distance from program to point of discovery: 0.3
Speed limit: 25
Temperature: 42
Wind speed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in deficiency finding for failing to follow door alarm policy and receiving training on door alarms |
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 2
Date: Apr 3, 2024
Visit Reason
The inspection was conducted as part of the investigation of Complaint #116338-C and the recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Complaint Details
The visit was triggered by Complaint #116338-C. The complaint was found to be credible as evidenced by the deficiencies cited related to medication administration and record checks.
Findings
The inspection found regulatory insufficiencies related to medication administration and record checks. Specifically, the program failed to administer prescribed medications to tenants and failed to complete background checks for employees prior to hire.
Deficiencies (2)
Failure to administer medications and treatments as prescribed to tenants.
Failure to complete background checks prior to employment for 4 of 5 employees reviewed.
Report Facts
Number of tenants without cognitive impairment: 20
Number of tenants with cognitive impairment: 2
Total census: 22
Number of tenants reviewed for medication administration: 4
Number of employees reviewed for background checks: 5
Compliance date for plan of correction: Jun 24, 2024
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 1
Date: Oct 12, 2022
Visit Reason
The inspection was conducted as part of an investigation of Complaint #108248-C regarding regulatory insufficiency related to service plans.
Complaint Details
The investigation was triggered by Complaint #108248-C. The deficiency was substantiated based on interviews and record reviews showing failure to update service plans appropriately.
Findings
The program failed to update service plans as needed for 1 of 5 tenants reviewed, specifically Tenant #1, whose service plan did not include interventions for inappropriate sexual behaviors despite documented incidents.
Deficiencies (1)
Failure to update service plans as needed for Tenant #1, including lack of interventions for inappropriate sexual behaviors.
Report Facts
Number of tenants without cognitive impairment: 22
Number of tenants with cognitive impairment: 0
Total census: 22
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 0
Date: May 31, 2022
Visit Reason
Investigation of Incident #104031-I and Complaint #104726-C at Pine Acres Assisted Living.
Complaint Details
Investigation of Incident #104031-I and Complaint #104726-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the incident and complaint.
Report Facts
Number of tenants without cognitive disorder: 22
Number of tenants with cognitive disorder: 0
Total Population of Program: 22
Inspection Report
Renewal
Census: 21
Deficiencies: 2
Date: Nov 22, 2021
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification of an Assisted Living Program, including investigation of Incident #100877-1 and a recertification visit.
Findings
Regulatory insufficiencies were cited related to program notification to the department and individualized service plans. Specifically, the program failed to notify the department timely of incidents and failed to develop individualized service plans reflecting tenant needs and preferences, including alcohol dependence and suicidal ideations.
Deficiencies (2)
Program notification to the department was not met as required when a tenant attempted suicide.
Service plans were not individualized and failed to reflect tenant needs and preferences, including alcohol dependence and suicidal ideations.
Report Facts
Number of tenants without cognitive disorder: 21
Number of tenants with cognitive disorder: 0
Total population of program at time of on-site: 21
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 1
Date: Jul 28, 2020
Visit Reason
The inspection was conducted as an investigation of Complaint #89462-C and included an onsite infection control survey.
Complaint Details
Investigation of Complaint #89462-C found the program did not meet the requirement to conduct nurse reviews every 90 days for tenants receiving personal or health-related care, as evidenced by Tenant #1's file review.
Findings
The program failed to assess and document the health status of tenants every 90 days as required for 1 of 3 tenants reviewed. No regulatory insufficiencies were cited during the infection control survey.
Deficiencies (1)
Failure to assess and document the health status of tenants every 90 days as required for 1 of 3 tenants reviewed.
Report Facts
Number of tenants without cognitive disorder: 22
Number of tenants with cognitive disorder: 0
Total census of Assisted Living Program: 22
Inspection Report
Renewal
Census: 22
Deficiencies: 1
Date: Jan 29, 2020
Visit Reason
A recertification visit was conducted to determine compliance with certification for an Assisted Living Program.
Findings
The program failed to consistently ensure evaluations were completed with significant change for one of two tenants reviewed, specifically Tenant #1. The Registered Nurse confirmed failure to complete functional, cognitive, and health evaluations prior to Tenant #1's significant change.
Deficiencies (1)
Failure to consistently ensure evaluations were completed with significant change for Tenant #1.
Report Facts
Number of tenants without cognitive disorder: 22
Number of tenants with cognitive disorder: 0
Total census of Assisted Living Program: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse | Confirmed failure to complete functional, cognitive, and health evaluations prior to Tenant #1's significant change. | |
| Director of Assisted Living | Educated by the Administrator on the necessity of completing a significant change evaluation on any tenant. |
Inspection Report
Renewal
Census: 25
Deficiencies: 0
Date: Jan 17, 2018
Visit Reason
A recertification visit was conducted to determine compliance with certification for an Assisted Living Program. Complaint #73227-C was also investigated.
Complaint Details
Complaint #73227-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were identified during the recertification and complaint investigation.
Report Facts
Number of tenants without cognitive disorder: 25
Number of tenants with cognitive disorder: 0
Total census of Assisted Living Program: 25
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 1
Date: Oct 24, 2016
Visit Reason
The inspection was conducted as an investigation of Incident 62640-I related to medication administration concerns at Heritage Court Assisted Living.
Complaint Details
Investigation of Incident 62640-I found substantiated concerns regarding medication administration errors and policy non-compliance.
Findings
The investigation revealed multiple failures in following medication administration policies, including missing signatures and documentation errors for medications given to three tenants. The Program's medication policy was not consistently followed as confirmed by the Register Nurse.
Deficiencies (1)
Program failed to ensure staff consistently followed medication administration policy, affecting 3 tenants with multiple documentation and signing errors.
Report Facts
Number of tenants without cognitive disorder: 22
Number of tenants with cognitive disorder: 1
Total Population of Program at time of on-site: 23
Number of tenants affected by medication policy failure: 3
Inspection Report
Monitoring
Census: 27
Deficiencies: 0
Date: Jan 19, 2016
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation to determine compliance with certification of an Assisted Living Program.
Findings
No regulatory insufficiencies were found during this evaluation. The review of recertification documents was completed and accepted, including the State Fire Marshal's inspection and Facility Engineer's approval of evacuation plans.
Report Facts
Number of tenants without cognitive disorder: 26
Number of tenants with cognitive disorder: 1
Total population of program at time of on-site: 27
Inspection Report
Monitoring
Census: 28
Deficiencies: 4
Date: Dec 17, 2013
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review the Plan of Correction and regulatory compliance of Heritage Court Assisted Living in response to previously identified regulatory insufficiencies.
Findings
The report found regulatory insufficiencies in the areas of Medications, Evaluations, Service Plans, and Nurse Review. The Plan of Correction submitted by the facility was accepted by the Department of Inspections and Appeals.
Deficiencies (4)
Failure to complete evaluations of tenant functional, cognitive, and health status within required timeframes.
Service plans did not meet the identified needs of tenants and were not updated appropriately.
Medication administration did not follow accepted standards of practice, including hand hygiene and documentation issues.
Nurse reviews were incomplete and did not document whether physician orders were current or if adverse reactions occurred.
Report Facts
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 0
Total census: 28
Medications due at 8:00 a.m.: 12
Medications due at 8:00 a.m.: 7
Medications due at 8:00 a.m.: 16
Medications due at 8:00 a.m.: 8
Medications due at 8:00 a.m.: 10
Medications due at 8:00 a.m.: 3
Medications due at 8:00 a.m.: 9
Medications due at 8:00 a.m.: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori Miner | RN BSN | Monitor conducting the evaluation |
| Rose Boccella | Program Coordinator, Adult Services Bureau | Signed letter transmitting the Final Recertification Monitoring Evaluation Report |
Inspection Report
Monitoring
Census: 14
Deficiencies: 2
Date: Oct 26, 2011
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 for Heritage Court Assisted Living.
Findings
The program had no regulatory insufficiencies during this certification period. However, medication administration deficiencies were noted, including failure to maintain adequate medication supplies and incomplete documentation of medication administration and physician notification.
Deficiencies (2)
Failure to maintain adequate amounts of physician ordered medications for multiple tenants and failure to administer tenant medications according to physician orders with proper documentation.
Regulatory insufficiency related to medication administration by unlicensed assistive personnel instead of licensed nurses as required.
Report Facts
Number of tenants without cognitive disorder: 14
Number of tenants with cognitive disorder: 0
Total census: 14
Medication doses not signed as given: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maribeth Freland | RN Monitor | Monitor who conducted the evaluation visit |
| Dan Donohue | Administrator | Administrator of Heritage Court Assisted Living named in the report |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 4
Date: Jun 23, 2010
Visit Reason
A complaint investigation on-site visit was conducted at Heritage Court on June 23, 2010, to investigate allegations related to tenant care and service plan compliance.
Complaint Details
Complaint Allegation: It was alleged a tenant transferred to another facility and upon admission was diagnosed with a fracture of the superior pubic ramus. The investigation found no negligent care related to this allegation.
Findings
The investigation found regulatory insufficiencies in evaluation of tenant functional, cognitive, and health status, and service plan updates. No negligent care was found related to the complaint allegation of a tenant fracture after transfer.
Deficiencies (4)
Lack of documentation of completion of cognitive, functional, and health evaluations within required timeframes.
Service plans lacked evidence of updates to meet current tenant needs.
Clinical records lacked documentation of nurse review for changes in tenant condition over a three month period.
Failure to assess and document tenant health status and monitor progress at least every 90 days or with changes in health status.
Report Facts
Current number of tenants without cognitive disorder: 20
Current number of tenants with cognitive disorder: 1
Total Population: 21
Cognitive evaluation score: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor conducting the complaint investigation |
Inspection Report
Monitoring
Census: 25
Deficiencies: 3
Date: Dec 22, 2009
Visit Reason
The visit was a monitoring evaluation conducted as part of the recertification process for Heritage Court Assisted Living to review the Plan of Correction and assess compliance with regulatory requirements.
Findings
The evaluation found regulatory insufficiencies related to the program's failure to complete functional and health evaluations within required timeframes and to develop and update individualized service plans accordingly. No substantiated regulatory insufficiencies were noted during the recertification period.
Deficiencies (3)
The program did not evaluate each tenant’s functional, cognitive and health status within 30 days of occupancy and as needed, but not less than annually.
The program did not develop a service plan for each tenant based on evaluations conducted in accordance with regulations.
The program did not update a service plan within 30 days of occupancy and as needed, but not less than annually, by a multidisciplinary team.
Report Facts
Current number of tenants without cognitive disorder: 22
Current number of tenants with cognitive disorder: 3
Total Population: 25
Tenant meeting attendance: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the on-site monitoring evaluation |
Inspection Report
Monitoring
Census: 28
Deficiencies: 1
Date: Nov 20, 2007
Visit Reason
The visit was a final recertification monitoring evaluation conducted to assess compliance with assisted living program regulations at Heritage Court Assisted Living.
Complaint Details
There were no substantiated complaints during this certification period.
Findings
The evaluation found that tenants were generally satisfied with the program, staff, and services. However, a regulatory insufficiency was identified related to the lack of consistent orientation and training for direct care staff on safe and sanitary food handling prior to handling food.
Deficiencies (1)
The program did not consistently provide an orientation on sanitation and safe food handling prior to handling food.
Report Facts
Current number of tenants without cognitive disorder: 25
Current number of tenants with cognitive disorder: 3
Total Population: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gary Tiemeyer | Administrator | Named as Administrator of Heritage Court Assisted Living |
| Lincoln Newsom | RN | Monitor conducting the evaluation |
Inspection Report
Monitoring
Census: 27
Deficiencies: 2
Date: Nov 2, 2005
Visit Reason
An on-site monitoring evaluation was conducted to assess compliance with assisted living program regulations at Heritage Court Assisted Living.
Complaint Details
There are no substantiated complaints during this certification period.
Findings
The evaluation found regulatory insufficiencies including failure to consistently evaluate tenants' functional, health, and cognitive status within 30 days of admission and upon status changes, and failure to develop service plans in consultation with tenants and a multidisciplinary team.
Deficiencies (2)
The program does not consistently evaluate tenants within 30 days of admission and with the status change requiring a change in services.
The program does not develop service plans in consultation with tenants and a multi-disciplinary team that includes a health-care professional and other appropriate staff.
Report Facts
Current number of tenants without cognitive disorder: 24
Current number of tenants with cognitive disorder: 3
Total Population: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the evaluation |
| Gary Tiemeyer | Administrator | Facility administrator |
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