3 Reports
Inspection Report — Jun 5, 2025
Complaint Investigation
Date: Jun 5, 2025
Visit Reason
The inspection was conducted to investigate Complaints #127441-C and #127464-C and to perform a recertification visit to determine compliance with certification of a Dedicated Dementia Specific Assisted Living Program.
Complaint Details
The visit was complaint-related, investigating allegations involving Tenant C1 including potential abuse by Staff C and issues with incident reporting and staff training.
Findings
The Program failed to follow established policies and procedures including timely reporting of potential abuse, completion of incident reports, dependent adult abuse training for staff, and proper food temperature monitoring. Additionally, deficiencies were found in documentation of nurse's notes, updating service plans to reflect tenant needs, and ensuring health care professional orders were current.
Violations (4)
Failure to follow established policies and procedures including reporting allegations of potential abuse, completion of incident reports, dependent adult abuse training, and food temperature monitoring.
Failure to document nurse's notes by exception for one tenant.
Failure to update service plans as needed to reflect tenant needs for multiple tenants.
Failure to ensure health care professionals' orders were current for a discharged tenant receiving program-administered medications.
Report Facts
Incident report completion dates: 3
Staff training dates: 2
Food temperature readings: 5
Medication orders: 4
Service plans updated: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in findings related to failure to complete dependent adult abuse training timely and incomplete incident reporting | |
| Staff B | Named in findings related to failure to complete dependent adult abuse training timely | |
| Staff C | Named in abuse allegation involving Tenant C1 | |
| Healthcare Coordinator | Involved in reviewing abuse allegations and incident reports | |
| Executive Director | Involved in abuse allegation response and staff training | |
| Culinary Coordinator #1 | Reported food temperatures were taken but not recorded | |
| Culinary Coordinator #2 | Reported food temperatures were taken daily and recorded |
Inspection Report — Nov 26, 2024
Complaint Investigation
Date: Nov 26, 2024
Visit Reason
The inspection was conducted to investigate Incident #123918-I and Complaint #124909-C regarding regulatory insufficiencies related to food labeling and storage, tenant rights, staffing, evaluations, service plans, and nurse reviews at Arlington Place of Oelwein.
Complaint Details
The complaint investigation substantiated maltreatment and verbal abuse by Staff G towards tenants, failure to treat tenants with respect and dignity, and multiple failures in documentation, communication, evaluations, and service planning.
Findings
The program failed to follow its policies and procedures related to food labeling and storage, resulting in unlabeled and improperly stored food items. There were substantiated complaints of verbal abuse and maltreatment by staff, failure to ensure tenants were treated with respect and dignity, inadequate communication and documentation of tenant health status, incomplete evaluations and service plans, and failure to complete nurse reviews as required.
Violations (7)
Program failed to follow policy and procedure related to food labeling and storage, affecting all tenants (census of 23).
Program failed to ensure tenants were treated with consideration, respect, and full recognition of personal dignity, involving maltreatment and verbal abuse by Staff G.
Program failed to communicate in writing occurrences that differed from a tenant's normal health, functional, and cognitive status and failed to retain documentation for at least three years.
Program failed to complete evaluations as needed with significant change for 3 of 4 tenants reviewed.
Program failed to update service plans to reflect identified needs of tenants for 4 of 4 tenants reviewed.
Program failed to complete nurse reviews as needed with changes in health status for 1 tenant reviewed who was hospitalized.
Program failed to discharge a tenant who exceeded retention criteria.
Report Facts
Number of tenants without cognitive disorder: 15
Number of tenants with cognitive disorder: 8
Number of tenants reviewed for evaluations: 4
Number of tenants reviewed for nurse communication documentation: 1
Number of tenants reviewed for nurse reviews: 1
Number of tenants reviewed for retention criteria: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Named in findings related to verbal abuse, maltreatment, and failure to follow policies | |
| Staff B | Witness and reporter in maltreatment and verbal abuse incidents | |
| Staff C | Witness and reporter in maltreatment and verbal abuse incidents | |
| Staff D | Witness and reporter in maltreatment and verbal abuse incidents | |
| Healthcare Coordinator | Interviewed regarding food labeling and maltreatment incidents | |
| Executive Director | Interviewed regarding maltreatment and staff behavior |
Inspection Report — Mar 1, 2023
Renewal
Date: Mar 1, 2023
Visit Reason
The visit was conducted as a recertification to determine compliance with certification rules for a Dementia-Specific Assisted Living Program and included investigation of related incidents and complaints.
Findings
No regulatory insufficiencies were cited during the recertification visit or during the investigation of Incident #107104-I, Complaint #110340-C, and Incident #107834-I.
Report Facts
Number of tenants without cognitive impairment: 25
Number of tenants with cognitive impairment: 6
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