Inspection Reports for
Addington Place of Burlington
5175 West Avenue, Burlington, IA, 52601
Back to Facility Profile10 Reports
Inspection Report — May 26, 2026
Enforcement
Date: May 26, 2026
Visit Reason
Investigation of Incident #131514-I, Complaint #132044-C, and Complaint #132142-C.
Complaint Details
Incident #131514-I, Complaint #132044-C, Complaint #132142-C
Findings
The facility failed to ensure staff provided care, safety checks, medication administration, and blood pressure monitoring according to training and service plans for Tenant #1. Evaluations were not completed for significant changes in condition, documentation was inaccurate, and service plans lacked required updates and individual tenant needs. Tenant #1 was missing from the facility overnight without staff knowledge.
Violations (5)
481-67.9(4)f Staffing: Staff failed to provide care, safety checks, medication administration, and blood pressure monitoring according to training and individual service plans for Tenant #1. Staff falsified safety check documentation and left medication unattended.
481-69.22(3) Evaluation of Tenant: The program failed to complete evaluations addressing significant changes in Tenant #1's condition despite documented behavioral and health changes.
481-69.25(1)q Tenant Document: The program failed to ensure accurate documentation on task sheets and medication administration records for Tenant #1, including contradictory and inaccurate medication administration entries.
481-69.26(3) Service Plans: The program failed to update Tenant #1's service plan within 30 days of admission.
481-69.26(4)a Service Plans: Tenant #1 and Tenant #4's service plans lacked individualized needs and preferences, including behavioral concerns, medication requests, and bathroom monitoring and sanitation instructions.
Inspection Report — Jan 15, 2026
Renewal
Date: Jan 15, 2026
Visit Reason
The visit was a recertification to determine compliance with certification rules for an Assisted Living Program for People with Dementia.
Findings
The program failed to discharge or request a waiver for one tenant who was bed-bound and exceeded retention criteria. The program also failed to adequately document health information for one tenant and failed to develop or update service plans for multiple tenants. Additionally, the program failed to complete thorough nurse reviews for tenants as required.
Violations (6)
481-69.23(1)a The program failed to discharge or request a waiver for one tenant who was bed-bound and exceeded criteria for retention in the assisted living program.
481-69.25(1)i The program failed to adequately document health information regarding a change of medical condition for one of six tenants reviewed.
481-69.26(1) The program failed to develop and update service plans to meet tenants' needs for four of six tenants reviewed.
481-69.26(2) The program failed to develop signed, dated preliminary service plans prior to occupancy for two tenants who moved into the program within the past three months.
481-69.26(3) The program failed to update service plans within 30 days of occupancy and as needed with significant changes for two tenants who moved into the program within the past three months.
481-69.27(1)a The program failed to complete thorough nurse reviews at least every 90 days for four tenants who had resided at the program for at least 90 days.
Inspection Report — Jul 28, 2025
Complaint Investigation
Date: Jul 28, 2025
Visit Reason
The inspection was conducted to investigate Incident #129056-I and Complaint #129767-C at the assisted living facility.
Complaint Details
Investigations of Incident #129056-I and Complaint #129767-C were conducted and found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigations of the incident and complaint.
Report Facts
Number of tenants without cognitive impairment: 37
Number of tenants with cognitive impairment: 9
Inspection Report — Mar 11, 2025
Plan of Correction
Date: Mar 11, 2025
Visit Reason
The document is a plan of correction related to investigations of specific complaint or incident numbers at an assisted living program for people with dementia.
Findings
No regulatory insufficiencies were cited during the investigations of complaint or incident numbers #125242-I, #125810-C, #124869-I, or #126903-M.
Report Facts
Number of tenants without cognitive impairment: 43
Number of tenants with cognitive impairment: 17
Inspection Report — Nov 13, 2024
Complaint Investigation
Date: Nov 13, 2024
Visit Reason
The inspection was conducted as an investigation into complaints #122113-C and #124337-C regarding regulatory insufficiencies at Addington Place of Burlington.
Complaint Details
The investigation was triggered by complaints #122113-C and #124337-C. Findings were substantiated as the program failed to meet tenant rights and respite care service requirements.
Findings
The program failed to provide appropriate services to tenants, including inadequate documentation and assistance with incontinence care and respite care services. Specific deficiencies included failure to document care provided to tenants and failure to provide written directions for respite care needs.
Violations (2)
Failure to provide appropriate services to 2 of 3 tenants reviewed, including inadequate assistance with toileting and incontinence care.
Failure to provide written directions to staff regarding care needs for 1 former respite care individual.
Report Facts
Number of tenants without cognitive impairment: 33
Number of tenants with cognitive impairment: 14
Dates missing documentation for Tenant #1: 18
Dates missing documentation for Tenant #2: 22
Inspection Report — Jul 11, 2024
Complaint Investigation
Date: Jul 11, 2024
Visit Reason
Investigation of Complaint #118616-C at Addington Place of Burlington.
Complaint Details
Investigation of Complaint #118616-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Report Facts
Number of tenants without cognitive impairment: 41
Number of tenants with cognitive impairment: 12
Inspection Report — Nov 15, 2023
Renewal
Date: Nov 15, 2023
Visit Reason
The visit was conducted as a recertification to determine compliance with certification for an Assisted Living Program for People with Dementia, including investigation of related complaints and incidents.
Complaint Details
The investigation into Complaint #116720-C, Incident #114007-I, and Incident #114660-I found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the recertification visit or during the investigation into Complaint #116720-C and related incidents.
Report Facts
Number of tenants without cognitive disorder in general population: 31
Number of tenants with cognitive disorder in general population: 2
Number of tenants without cognitive disorder in memory care unit: 0
Number of tenants with cognitive disorder in memory care unit: 15
Inspection Report — Jun 23, 2022
Complaint Investigation
Date: Jun 23, 2022
Visit Reason
Investigation into Complaint #100395-C regarding the Assisted Living Program for People with Dementia.
Complaint Details
Complaint #100395-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder in General Population: 15
Number of tenants with cognitive disorder in General Population: 10
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 9
Inspection Report — Aug 12, 2021
Renewal
Date: Aug 12, 2021
Visit Reason
Recertification visit conducted to determine compliance with certification for an Assisted Living Program for People with Dementia and to conduct an onsite infection control survey.
Findings
No regulatory insufficiencies were cited during the recertification visit or the onsite infection control survey.
Inspection Report — Oct 29, 2020
Complaint Investigation
Date: Oct 29, 2020
Visit Reason
The inspection was conducted as a complaint investigation into multiple complaints (93137-C, 93138-C, and 91278-C) and an onsite infection control survey. The visit aimed to investigate alleged regulatory insufficiencies related to tenant rights, tenant documents, service plans, and nurse reviews.
Complaint Details
The complaint investigation was triggered by complaints #93137-C, 93138-C, and 91278-C. No regulatory insufficiencies were cited during the investigation of Complaint #93742-C or the onsite infection control survey. The findings related to tenant rights, documentation, service plans, and nurse reviews were substantiated during the investigation.
Findings
The investigation found regulatory insufficiencies including failure to ensure tenants were free from restraints, incomplete tenant documentation such as missing powers of attorney, failure to update service plans after significant changes, and failure to conduct nurse reviews after significant changes in tenant conditions. Multiple tenants had incidents involving falls, injuries, and unmet care needs.
Violations (4)
Failure to ensure restraints were not utilized for 1 of 5 tenants reviewed (Tenant #4).
Failure to maintain required tenant documents including power of attorney paperwork for Tenant #3.
Failure to update service plans within 30 days of significant change for 4 of 5 tenants reviewed.
Failure to ensure nurse reviews were completed with significant changes for 4 of 5 tenants reviewed.
Report Facts
Number of tenants without cognitive disorder in general population: 37
Number of tenants with cognitive disorder in general population: 4
Number of tenants without cognitive disorder in memory care unit: 0
Number of tenants with cognitive disorder in memory care unit: 8
Tenants reviewed for deficiencies: 5
Tenants reviewed for documentation: 4
Tenants reviewed for nurse reviews: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Reported involvement in restraint use and COVID-19 testing process for Tenant #4 | |
| Health Services Director | Health Services Director (HSD) | Involved in restraint use, care plan updates, nurse reviews, and confirming findings |
| Executive Director | Executive Director | Confirmed findings and involved in corrective actions |
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