5 Reports
Inspection Report — Oct 3, 2024
Renewal
Date: Oct 3, 2024
Visit Reason
The visit was a recertification inspection to determine compliance with certification rules for an Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the recertification visit.
Report Facts
Number of tenants without cognitive impairment: 1
Number of tenants with cognitive impairment: 13
Inspection Report — Sep 27, 2023
Complaint Investigation
Date: Sep 27, 2023
Visit Reason
The inspection was conducted as part of the investigation of Complaint #109278-C regarding regulatory insufficiencies at the assisted living program.
Complaint Details
The visit was triggered by Complaint #109278-C. The complaint involved concerns about falls, bruising, skin breakdown, and inadequate care for Tenant #1. The complaint was substantiated as deficiencies were found.
Findings
The program failed to follow established policies and procedures related to incident reports and head injuries, failed to provide adequate and appropriate care, did not evaluate tenant eligibility prior to occupancy or with significant changes, failed to document nurse's notes by exception, did not update service plans based on evaluations, and failed to conduct nurse reviews at least every 90 days for tenants receiving personal or health-related care. These deficiencies pertained to Tenant #1 among three tenants reviewed.
Violations (7)
Failed to follow established policies and procedures for incident reports and head injuries.
Failed to provide adequate and appropriate care to tenants.
Failed to evaluate functional, cognitive, and health status prior to occupancy to determine eligibility.
Failed to evaluate functional, cognitive, and health status annually and with significant change.
Failed to document nurse's notes by exception.
Failed to update service plans based on required evaluations.
Failed to assess and document health status of tenants receiving personal or health-related care at least every 90 days.
Report Facts
Number of tenants with cognitive impairment: 15
Weight loss: 36
Date of inspection: Sep 27, 2023
Inspection Report — Apr 11, 2023
Complaint Investigation
Date: Apr 11, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to Incident #111812-I and Complaint 111084-C at Independence Village of Waukee MC.
Complaint Details
The visit was complaint-related, investigating Incident #111812-I and Complaint 111084-C. No regulatory insufficiencies were cited during the investigation of Incident #111812-I, but deficiencies were cited during the investigation of Complaint 111084-C.
Findings
The investigation found multiple regulatory deficiencies including failure to consistently follow incident reporting policy, incomplete staff training and nurse delegation within required timeframes, failure to ensure dependent adult abuse training compliance, incomplete criminal history evaluations prior to employment, failure to use the required Global Deterioration Scale for cognitive evaluation, inadequate documentation of routine personal and health-related care, and failure to implement/document emergency response procedures for tenants with cognitive disorders.
Violations (7)
Failure to consistently follow incident reporting policy for Tenant #3's fall incident.
Delegating nurse failed to ensure staff training within required timeframes for 5 tenants.
Program failed to ensure staff received required Dependent Adult Abuse training.
Failure to perform criminal history evaluations prior to employment for Staff A.
Failure to utilize the Global Deterioration Scale for tenants with moderate cognitive decline.
Failure to maintain accurate documentation on task sheets for routine personal and health-related care for 5 tenants.
Failure to implement and document staff procedures addressing emergency needs of tenants with cognitive disorders.
Report Facts
Number of tenants without cognitive impairment: 1
Number of tenants with cognitive impairment: 12
Number of tenants affected by staff training deficiency: 5
Number of tenants potentially affected by staff training deficiency: 8
Number of tenants potentially affected by dependent adult abuse training deficiency: 13
Number of tenants reviewed for cognitive evaluation deficiency: 5
Number of tenants reviewed for documentation deficiency: 5
Number of tenants reviewed for emergency procedure deficiency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Hired 1/3/23; criminal history evaluation completed after employment start date | |
| Staff B | Hired 7/21/21; nurse aide checklist completed 11/30/22 | |
| Staff C | Hired 11/1/19; nurse aide checklist completed 11/30/22; last Dependent Adult Abuse training completed 3/11/16 | |
| Wellness Coordinator | Delegating Nurse | Hired 6/20/22; failed to ensure timely staff training and incident report documentation |
| Regional Wellness Director | Confirmed failure to ensure criminal history evaluation prior to employment | |
| Wellness Director | Confirmed use of BCRS instead of required Global Deterioration Scale |
Inspection Report — Jun 16, 2022
Renewal
Date: Jun 16, 2022
Visit Reason
A recertification visit was conducted to determine compliance with certification for an Assisted Living Program for People with Dementia. During the recertification visit, investigations 104577-C & 97810-C were also completed.
Findings
The Program failed to ensure tenants received adequate and appropriate care, specifically Tenant #1 did not receive prescribed pain medication due to unavailability. The Program also failed to consistently perform required criminal history and abuse record checks prior to employment and failed to consistently evaluate tenants' functional status annually or with significant change.
Violations (3)
Failed to ensure Tenant #1 received prescribed pain medication (Tramadol) as it was unavailable, resulting in missed doses.
Failed to consistently perform criminal history and child/dependent adult abuse record checks prior to employment for Staff A.
Failed to consistently evaluate tenants' functional status annually or with significant change, specifically Tenant #1 had no current cognitive evaluation.
Report Facts
Number of tenants with cognitive disorder: 12
Missed medication doses: 16
Staff reviewed: 4
Tenants reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Failed to receive criminal history and abuse record checks prior to employment; unable to administer pain medication due to unavailability | |
| Registered Nurse | RN | Interviewed regarding medication unavailability and follow-up with supplier; confirmed lack of cognitive evaluation for Tenant #1; stated insufficient nursing staff |
Inspection Report — Feb 20, 2020
Complaint Investigation
Date: Feb 20, 2020
Visit Reason
Investigation of Incident #88159-I at the Assisted Living Program for People with Dementia.
Complaint Details
Investigation of Incident #88159-I found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation.
Report Facts
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 15
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