Inspection Reports for
Allen Place Senior Living
1406 E 19th St, Atlantic, IA 50022, United States, IA, 50022
Back to Facility Profile6 Reports
Inspection Report — Apr 28, 2026
Renewal
Date: Apr 28, 2026
Visit Reason
The visit was a recertification (renewal) visit to Allen Place. The investigation also covered Complaint #131278-C, Complaint #131529-C, and Incident #131920-I.
Complaint Details
Complaint #131278-C, Complaint #131529-C, and Incident #131920-I were investigated during the visit.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints and incident.
Inspection Report — Jul 17, 2025
Complaint Investigation
Date: Jul 17, 2025
Visit Reason
The inspection was conducted as an investigation of Incident #129932-I and Complaints #129930-C, #129933-C, #129934-C, and #129950-C at Allen Place Assisted Living Program.
Complaint Details
The visit was complaint-related, investigating multiple complaints and an incident involving Tenant C1's fall and injury.
Findings
The program failed to ensure appropriate care and services for a tenant resulting in a fall and serious injury, failed to provide timely nurse delegation training for staff, failed to complete evaluations after significant tenant changes, retained a tenant requiring two-person assistance beyond program criteria, and failed to ensure the delegating nurse completed required assisted living management training within six months of hire.
Violations (6)
Failed to ensure appropriate care, treatment, and services for Tenant C1, who fell in the shower due to lack of proper stand by assistance and missing non-skid bathmat.
Failed to ensure program staff received nurse delegation training within 30 days of employment for 3 of 7 staff reviewed.
Failed to complete evaluation due to significant change for Tenant 3 after hospice admission.
Retained Tenant 4 who routinely required two-person assistance with transfers and toileting, exceeding program admission/retention criteria.
Failed to ensure all personnel received training appropriate to assigned tasks and target population, specifically Staff C.
Failed to ensure the delegating nurse completed an assisted living manager or nursing class within six months of hire.
Report Facts
Number of tenants without cognitive impairment: 23
Number of tenants with cognitive impairment: 13
Staff reviewed for nurse delegation training: 7
Staff failed nurse delegation training within 30 days: 3
Date of incident: Jul 8, 2025
Date of survey completion: Jul 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Staff responsible for assisting Tenant C1 during fall incident; lacked proper training and supervision. | |
| Executive Director/Nurse | Executive Director/Nurse | Interviewed regarding training deficiencies and program policies; confirmed findings and incomplete training. |
| Staff A | Staff reviewed for nurse delegation training; training completed late. | |
| Staff B | Staff reviewed for nurse delegation training; training completed late. | |
| Staff D | Staff interviewed regarding Tenant 4's need for two-person assistance. | |
| Staff E | Staff interviewed regarding Tenant 4's need for two-person assistance. | |
| Staff F | Staff interviewed regarding Tenant 4's need for two-person assistance. | |
| Licensed Practical Nurse (LPN) | Licensed Practical Nurse | Hospice nurse providing services to Tenant 4; confirmed two-person assistance requirement. |
Inspection Report — Jul 15, 2025
Enforcement
Date: Jul 15, 2025
Visit Reason
This citation was issued following a survey conducted from 7/15/25 to 7/17/25 regarding multiple actions including 129932-I, 129930-C, 129933-C, 129934-C, and 129950-C. The citation addresses failures in tenant care and staff training.
Findings
The program failed to provide appropriate care and services to a former tenant who suffered a fall and fatal brain hemorrhage due to inadequate supervision during showering. Additionally, one staff member did not receive training appropriate to assigned tasks and target population as required.
Violations (2)
481-67.3(2) Tenant rights: The program failed to ensure appropriate care and services for Tenant C1, who slipped and fell in the shower without a non-skid bathmat in place, resulting in serious injury and subsequent death. Staff C misunderstood the required level of assistance and left the tenant unsupervised during the shower.
481—69.29(231C) Staffing: The program failed to ensure that Staff C received training appropriate to assigned tasks and target population. Staff C's orientation and delegation checklist was incomplete, lacking signatures and dates for required training, and he provided care without proper supervision.
Report Facts
Fine amount: 10000
Inspection Report — Nov 7, 2024
Renewal
Date: Nov 7, 2024
Visit Reason
The visit was conducted as a recertification inspection to determine compliance with certification rules for an Assisted Living Program.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaints #118038-C and 123706-C.
Findings
No regulatory insufficiencies were cited during the complaint investigations. However, deficiencies were found during the recertification visit related to failure to consistently perform criminal background checks prior to employment and failure to ensure service plans were based on timely evaluations for tenants.
Violations (2)
Program failed to consistently perform criminal background checks prior to employment, pertaining to 1 of 2 staff reviewed (Staff A).
Program failed to consistently ensure service plans were based on evaluations (cognitive, functional, and health) for 4 of 4 tenants reviewed.
Report Facts
Number of tenants without cognitive impairment: 19
Number of tenants with cognitive impairment: 17
Staff reviewed for background check compliance: 2
Tenants reviewed for service plans: 4
Inspection Report — Jan 31, 2023
Complaint Investigation
Date: Jan 31, 2023
Visit Reason
The inspection was conducted to investigate Incident #108571-I and Complaint 105369-C at Allen Place, an assisted living facility.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint 105369-C. The deficiency cited was related to Incident #108571-I.
Findings
No regulatory insufficiencies were cited during the complaint investigation, but a deficiency was found related to nurse delegation training. The program's delegating nurse failed to ensure staff received required training within 30 days of employment, potentially affecting all 28 tenants.
Violations (1)
The program's delegating nurse failed to consistently ensure staff were trained to meet the individual needs of tenants within 30 days of employment.
Report Facts
Number of tenants without cognitive impairment: 20
Number of tenants with cognitive impairment: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in deficiency for not receiving required nurse delegation training within 30 days of employment |
Inspection Report — Jul 13, 2021
Renewal
Date: Jul 13, 2021
Visit Reason
The inspection was a recertification visit conducted to determine compliance with certification of an Assisted Living Program.
Findings
Two regulatory deficiencies were cited: failure to include a list of person-centered planned and spontaneous activities for tenants unable to plan their own activities, and failure to provide annual in-service training on safe food handling for 4 of 8 staff reviewed.
Violations (2)
Failed to include a list of person-centered planned and spontaneous activities for tenants unable to plan their own activities, including those with dementia.
Failed to provide annual in-service training on safe food handling for 4 of 8 staff responsible for food preparation or service.
Report Facts
Number of tenants without cognitive disorder: 29
Number of tenants with cognitive disorder: 9
Total Population of Program at time of on-site: 38
Staff without annual food safety training: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in finding for lack of annual food safety and sanitation training | |
| Staff B | Named in finding for lack of annual food safety and sanitation training | |
| Staff C | Named in finding for lack of annual food safety and sanitation training | |
| Staff D | Named in finding for lack of annual food safety and sanitation training | |
| Care Services Manager | Confirmed findings related to service plans for tenants with cognitive impairment | |
| Executive Director | Confirmed findings related to food service training deficiencies and implemented corrective actions |
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