Inspection Report Summary
The most recent inspection on October 27, 2025, found no deficiencies during a complaint investigation. Earlier inspections showed a mixed pattern, with some citations related to tenant evaluations, service plans, and staff training in dementia care, as well as issues with admission criteria and medication administration in prior years. Complaint investigations were mostly unsubstantiated, except for a few substantiated cases involving medication errors, incident reporting, and tenant behavior management, including a civil penalty issued in 2012 for retaining tenants with behaviors that posed risks. Enforcement actions included a $1,000 fine in 2012, but no fines or license actions were listed in the more recent reports. The overall trend suggests improvement, with the most recent inspections free of deficiencies after earlier challenges.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
77% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
27 residents
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 0
Date: Oct 27, 2025
Visit Reason
Investigation of Incident #130455-I at an assisted living program serving people with dementia.
Complaint Details
Investigation of Incident #130455-I; no regulatory insufficiencies found.
Findings
No regulatory insufficiencies were cited during the investigation.
Report Facts
Tenants without cognitive impairment: 25
Tenants with cognitive impairment: 12
Total census: 27
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 0
Date: Jun 19, 2025
Visit Reason
The inspection was conducted as an investigation of Incident #128041-C at the assisted living program for people with dementia.
Complaint Details
Investigation of Incident #128041-C with no regulatory insufficiencies cited.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #128041-C.
Report Facts
Number of tenants without cognitive impairment: 26
Number of tenants with cognitive impairment: 11
Total census: 37
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 0
Date: Mar 27, 2025
Visit Reason
Investigation of Incident #127418-I at the assisted living program for people with dementia.
Complaint Details
Investigation of Incident #127418-I; no regulatory insufficiencies found.
Findings
No regulatory insufficiencies were cited during the investigation.
Report Facts
Number of tenants without cognitive impairment: 25
Number of tenants with cognitive impairment: 3
Total census: 28
Inspection Report
Renewal
Census: 41
Deficiencies: 0
Date: Jan 7, 2025
Visit Reason
The visit was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program and included investigation of two complaints.
Complaint Details
Investigation of Complaints #121443-C and #121982-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of Complaints #121443-C and #121982-C, nor during the recertification visit for the Assisted Living Program.
Report Facts
Tenants without cognitive impairment: 30
Tenants with cognitive impairment: 11
Total census: 41
Inspection Report
Renewal
Census: 31
Deficiencies: 3
Date: Jul 26, 2022
Visit Reason
The visit was conducted as a recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #100155-C and #106168-C.
Findings
No regulatory insufficiencies were cited during the investigation of two complaints. However, during the recertification visit, regulatory insufficiencies were cited related to evaluation of tenants, service plans, and dementia-specific education for personnel.
Deficiencies (3)
Program failed to evaluate a tenant's functional, cognitive, and health status at least annually for 1 of 2 tenants reviewed.
Program failed to update service plans on an annual basis for 1 of 2 tenants reviewed.
Program failed to provide 8 hours of dementia training within 30 days of employment for 2 of 8 staff reviewed.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 20
Number of tenants with cognitive disorder in General Population Program: 4
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 7
Total census of Assisted Living Program for People with Dementia: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Confirmed findings related to dementia-specific education for personnel and tenant evaluations. | |
| RN Director of Health and Wellness | Registered Nurse | Confirmed findings and completed the full annual assessment and updated service plan for Tenant #1. |
| Staff A | Staff member who did not receive dementia training within 30 days of employment. | |
| Staff B | Staff member who did not receive dementia training within 30 days of employment. |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 0
Date: Nov 2, 2020
Visit Reason
Investigation of Complaint #90640-C and an onsite infection control survey.
Complaint Details
Complaint #90640-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint or the onsite infection control survey.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 29
Number of tenants with cognitive disorder in General Population Program: 4
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 10
Total census: 43
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Date: Feb 13, 2020
Visit Reason
The inspection was conducted as an investigation of Complaint #87586-C regarding the admission and retention criteria for tenants requiring assistance with standing, transfer, or evacuation.
Complaint Details
Investigation of Complaint #87586-C found regulatory insufficiency related to admission and retention criteria for tenants requiring two-person assistance. The complaint was substantiated with observations and staff interviews confirming the issue.
Findings
The program failed to ensure that two of three tenants reviewed did not exceed the level of care criteria requiring routine two-person assistance for transfers. Observations and interviews confirmed that tenants required two staff for transfers, but this was not consistently provided.
Deficiencies (1)
Failure to meet criteria for admission and retention of tenants requiring routine, two-person assistance with standing, transfer, or evacuation.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 31
Number of tenants with cognitive disorder in General Population Program: 2
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 10
Total census of Assisted Living Program for People with Dementia: 35
Date of observations: Feb 10, 2020
Date of observations: Feb 11, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Windsor Manor DHW | Director of Health & Wellness | Named in plan of correction to ensure criteria for admission/retention and staff education |
| Staff A | Observed and reported tenant transfer assistance requirements | |
| Staff B | Observed and reported tenant transfer assistance requirements | |
| Staff C | Observed and reported tenant transfer assistance requirements | |
| Executive Director | Stated tenant transfer assistance requirements |
Inspection Report
Renewal
Census: 45
Deficiencies: 0
Date: Nov 14, 2019
Visit Reason
Recertification visit conducted to determine compliance with certification of an Assisted Living Program for People with Dementia.
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 in General Population Program: 29
Number of tenants with cognitive disorder in General Population Program: 6
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 10
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 2
Date: Sep 27, 2018
Visit Reason
The inspection was conducted as an investigation of Complaint #77779-C regarding regulatory insufficiencies at the assisted living program.
Complaint Details
Investigation of Complaint #77779-C. The complaint was substantiated by findings of unreported incidents and medication administration errors.
Findings
The program failed to report all incidents affecting tenants as required by policy, specifically an injury to Tenant #2 that was not reported. Additionally, a medication error occurred when a Universal Worker administered another tenant's Lovenox injection to Tenant #1, contrary to policy.
Deficiencies (2)
Failure to ensure all incidents or unusual occurrences affecting tenants were reported per Program policy (Tenant #2 injury not reported).
Failure to ensure staff administered injections correctly; Tenant #1 was given another tenant's Lovenox injection by mistake.
Report Facts
Total Census: 39
Tenants without cognitive disorder (General Population): 29
Tenants with cognitive disorder (General Population): 0
Tenants without cognitive disorder (Memory Care Unit): 3
Tenants with cognitive disorder (Memory Care Unit): 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Healthcare Coordinator | Interviewed and confirmed no incident report existed for Tenant #2's injury and that a medication error occurred involving Tenant #1 | |
| Universal Worker A | Staff delegated to administer insulin injections who mistakenly administered Lovenox injection to Tenant #1 |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Date: May 23, 2018
Visit Reason
The inspection was conducted as an investigation of Incident #75357-I and Complaint #75351-C at the assisted living facility.
Complaint Details
Investigation of Incident #75357-I and Complaint #75351-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 in general population: 34
Number of tenants with cognitive disorder in general population: 0
Number of tenants without cognitive disorder in memory care unit: 3
Number of tenants with cognitive disorder in memory care unit: 7
Total census: 44
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Date: Jan 31, 2018
Visit Reason
Investigation of Incident #73321-I at the assisted living program for people with dementia.
Complaint Details
Investigation of Incident #73321-I with no regulatory insufficiencies cited.
Findings
No regulatory insufficiencies were cited during the 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: 3
Number of tenants with cognitive disorder in memory care unit: 7
Total census: 41
Inspection Report
Renewal
Census: 43
Deficiencies: 0
Date: Oct 24, 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 for the Assisted Living Program.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 33
Number of tenants with cognitive disorder in General Population Program: 0
Total Population of General Population Program: 33
Number of tenants without cognitive disorder in Dementia-Specific Program: 1
Number of tenants with cognitive disorder in Dementia-Specific Program: 9
Total Population of Dementia-Specific Program: 10
TOTAL census of Assisted Living Program: 43
Inspection Report
Monitoring
Census: 47
Deficiencies: 1
Date: Oct 15, 2015
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted by the Department of Inspections and Appeals (DIA) on October 12 and 15, 2015, to determine compliance with certification for an Assisted Living Program at Windsor Manor Nevada.
Findings
The report identified a regulatory insufficiency related to Food Service where the staff did not provide 100% of the daily recommended dietary allowances as portions of food were not supplied as written in the menu. Specific observations noted inadequate serving sizes in the dementia unit.
Deficiencies (1)
Food Service: Staff did not provide 100% of the daily recommended dietary allowances as portions of food were not supplied as written in the menu, specifically in the dementia unit.
Report Facts
Total census: 47
Number of tenants without cognitive disorder: 40
Number of tenants with cognitive disorder: 7
Inspection Report
Monitoring
Census: 34
Deficiencies: 0
Date: Apr 10, 2013
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review recertification documents and evaluate compliance with regulatory requirements for the Assisted Living Program at Windsor Manor.
Findings
No regulatory insufficiencies were found during this evaluation. The program did not receive any regulatory insufficiencies during this certification period, and the on-site monitoring evaluation noted no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 24
Number of tenants with cognitive disorder in General Population Program: 2
Total Population of General Population Program at time of on-site: 26
Number of tenants without cognitive disorder in Dementia-Specific Program: 1
Number of tenants with cognitive disorder in Dementia-Specific Program: 7
Total Population of Dementia-Specific Program at time of on-site: 8
Total census of Assisted Living Program: 34
Number of tenants attending Tenant/Family Satisfaction meeting: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori Miner | RN BSN | Monitor conducting the evaluation |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Date: Oct 16, 2012
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding allegations of lack of nursing coverage, improper medication administration, inaccurate nurse review of blood pressures, and failure to follow directives from a tenant's power of attorney.
Complaint Details
The complaint investigation addressed allegations that the program did not have nursing coverage, tenants were not receiving medications as ordered, staff did not obtain accurate blood pressures using a pediatric cuff, and program administration did not follow directives from a tenant's power of attorney. The investigation found the nursing coverage allegation unsubstantiated, medication administration deficiencies substantiated with regulatory insufficiency noted, no regulatory insufficiency related to nurse review or administration directives.
Findings
The investigation found no regulatory insufficiency related to nursing coverage, nurse review, or administration directives. However, regulatory insufficiency was noted related to medication administration, specifically that medications were sometimes not given as ordered or not available, and administration was not always performed by qualified nursing personnel as required.
Deficiencies (1)
When medications are administered traditionally by the program, the administration of medications shall be provided by a registered nurse, licensed practical nurse, advanced registered nurse practitioner, or by unlicensed personnel in accordance with nurse delegation requirements.
Report Facts
Total census: 37
Tenants without cognitive disorder: 26
Tenants with cognitive disorder: 2
Total population: 28
Tenants without cognitive disorder: 1
Tenants with cognitive disorder: 8
Total population: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alison Kapustka | Manager | Program manager handling day to day operation during absence of on-site RN |
| Maribeth Freland | RN | Monitor conducting the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 1
Date: Jul 9, 2012
Visit Reason
The inspection was conducted as a Final Complaint/Incident Investigation Report for Windsor Manor Nevada, Iowa, following complaints about tenant behaviors and regulatory insufficiencies.
Complaint Details
The complaint involved tenant #1 exhibiting aggressive physical and sexual behaviors, wandering into other tenant rooms, and tenant #2 exhibiting hallucinations, exit-seeking, and aggressive behaviors. The program retained tenants despite these behaviors placing staff and others at risk. Law enforcement was involved on multiple occasions. The program failed to adequately address these behaviors and maintain safety.
Findings
The program was assessed a $1,000 civil penalty for failing to comply with regulatory requirements, resulting in imminent danger or substantial probability of death or physical harm to tenants. The program retained two tenants despite patterns of behavior placing staff and tenants at risk for injury.
Deficiencies (1)
Regulatory Insufficiencies in Criteria for Exclusion of Tenants, Evaluation, Service Plan and Policies and Procedures.
Report Facts
Civil penalty amount: 1000
Reduced penalty amount: 650
Complaint/Incident Investigation Dates: July 9 and 10, 2012
Total census: 36
Number of tenants without cognitive disorder: 26
Number of tenants with cognitive disorder: 10
Number of tenants in Dementia-Specific Program: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maribeth Freland | RN Monitor | Monitor who conducted the complaint/incident investigation |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter |
| Rose Boccella | Program Coordinator | Contact person for questions and appeals |
Inspection Report
Monitoring
Census: 28
Deficiencies: 1
Date: Sep 21, 2011
Visit Reason
An on-site monitoring evaluation was conducted to assess compliance with regulatory requirements and to evaluate the Assisted Living Program at Windsor Manor Nevada.
Findings
The report found that the facility had a total census of 28 residents, including 24 in the general population program and 4 in the dementia-specific program. A regulatory insufficiency was noted regarding delayed completion of criminal and abuse record checks for a staff member hired on 4-20-11, which was later cleared by the Department of Human Services.
Deficiencies (1)
Regulatory insufficiency related to delayed criminal, dependent adult, and child abuse record checks for Staff #3 hired on 4-20-11.
Report Facts
Number of tenants without cognitive disorder: 22
Number of tenants with cognitive disorder: 2
Total Population of Program at time of on-site: 24
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 4
Total Population of Program at time of on-site: 4
TOTAL census of Assisted Living Program: 28
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