Inspection Report Summary
The most recent inspection on August 21, 2025, found no deficiencies during a complaint investigation. Earlier inspections showed a mixed pattern, with some deficiencies related to medication administration, nursing documentation, and staff training, particularly involving one tenant’s care and medication management. Inspectors cited failures to follow policies for documenting health changes, incomplete nurse reviews, medication errors, and insufficient training for contract staff administering medications. Complaint investigations were mostly unsubstantiated except for a few substantiated cases involving documentation and medication issues, including one tenant who experienced worsening health and was found unresponsive. The facility’s recent clean inspection suggests some improvement following earlier identified issues.
Deficiencies (last 6 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a August 2025 inspection.
Census over time
Inspection Report
Complaint InvestigationInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff A | Reported Tenant C1's worsening condition and failure to complete RN Communication Forms | |
| Staff B | Observed Tenant C1's symptoms and failure to complete RN Communication Forms | |
| Staff D | Worked with Tenant C1 and failed to complete RN Communication Forms | |
| Staff F | Observed Tenant C1's condition and failed to complete RN Communication Forms | |
| Staff I | Observed Tenant C1's condition and failed to complete RN Communication Forms | |
| Healthcare Coordinator | HCC | Failed to document nurse's notes by exception and nurse reviews; received education and completed late entry documentation |
| Community Director | Confirmed staff failures and responsible for compliance oversight | |
| Triage Nurse 1 | On call during weekend of 1/11/25 and 1/12/25; did not complete nurse review in person |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Healthcare Coordinator | Confirmed lack of medication orders and service plan deficiencies related to Tenant C1 | |
| Community Director | Confirmed findings related to medication administration and service plan deficiencies for Tenant C1 | |
| On-Call Registered Nurse | Administered medication discontinuation orders and failed to notify family as required |
Inspection Report
Complaint InvestigationInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Regional Assisted Living Director-Iowa | Interviewed and confirmed failure to ensure contract/agency staff received required training | |
| AL Health Specialist | Confirmed staff administering morphine and training deficiencies |
Inspection Report
RenewalInspection Report
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