11 Reports
Inspection Report — Apr 15, 2026
Renewal
Date: Apr 15, 2026
Visit Reason
Scheduled recertification visit to determine compliance with certification of an Assisted Living Program. The visit also investigated Complaint #131528-C, Complaint #131663-C, Incident #131726-I, and Complaint #131835-C.
Complaint Details
Complaint #131528-C, Complaint #131663-C, Incident #131726-I, Complaint #131835-C
Findings
Regulatory insufficiencies were cited related to housekeeping and laundry services, reasonable responses to tenant requests, and individualized service plans. No infection control concerns were observed.
Violations (4)
481-67.3(2) Tenant Rights: The program failed to provide adequate and appropriate housekeeping and laundry services for 3 out of 12 tenants. Tenants reported weeks without housekeeping and laundry services, and observations confirmed unclean conditions.
481-67.3(5) Tenant Rights: The program failed to provide reasonable responses to tenant requests for 4 out of 12 tenants. Tenants reported ignored concerns about rent increases and housekeeping, and the Executive Director was unresponsive.
481-69.26(4)a Service Plans: The program failed to ensure service plans were individualized and included all identified needs for 1 out of 12 tenants. The service plan did not identify custom interventions to decrease fall risk.
481-69.26(4)c Service Plans: The program failed to identify all outside service providers within resident service plans for 1 out of 12 tenants. The service plan lacked information about providers assisting with occupational and physical therapy.
Inspection Report — Oct 15, 2024
Complaint Investigation
Date: Oct 15, 2024
Visit Reason
The inspection was conducted following the investigation of Incident #123945-I, Incident #123685-I, and Complaint #123922-C related to medication administration errors and narcotic discrepancies at Eagle Pointe Place Assisted Living.
Complaint Details
The visit was complaint-related, investigating incidents and a complaint involving medication errors and narcotic discrepancies. The complaint was substantiated with findings of medication errors and improper narcotic handling.
Findings
The investigation found staff failed to follow established medication administration policies for multiple tenants, resulting in a medication error where Tenant #1 received Tenant #2's medications causing hospitalization. Additionally, discrepancies in narcotic medication counts were discovered, with evidence of medication destruction by staff to conceal errors. Staff involved were terminated and retraining and competency evaluations were implemented.
Violations (2)
Staff failed to follow the Program's established policies regarding medication administration for Tenant #1 and Tenant #2, resulting in Tenant #1 receiving Tenant #2's medications.
Staff failed to provide services in accordance with training for Tenant #3 and Tenant #4 regarding narcotic medication counts, including destruction of medication to conceal discrepancies.
Report Facts
Number of tenants without cognitive impairment: 85
Number of tenants with cognitive impairment: 4
Medication error incident date: Oct 8, 2024
Narcotic discrepancy date: Sep 16, 2024
Number of Lorezepam tablets counted first shift: 18
Number of Lorezepam tablets counted third shift: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in medication administration error involving Tenant #1 and Tenant #2 | |
| Staff E | Reported medication error and involved in medication administration incident | |
| Staff A | Involved in narcotic count discrepancy and medication destruction | |
| Staff B | Involved in narcotic count discrepancy | |
| Staff D | Medication manager who observed improper medication pass practices by Staff C | |
| Staff I | Witnessed Staff A destroying medication during narcotic count | |
| Executive Director | Executive Director | Confirmed findings and conducted staff retraining |
| Director of Health Services | Director of Health Services | Confirmed findings, conducted investigation, and retraining |
| Assistant Director of Health Services | Assistant Director of Health Services | Conducted investigation and interviews related to medication errors and narcotic discrepancies |
Inspection Report — Oct 10, 2024
Enforcement
Date: Oct 10, 2024
Visit Reason
This citation was issued following a review of medication administration practices at Eagle Pointe Place from 10/10/24 to 10/15/24. The citation addresses failures in following the program's established medication administration policies.
Findings
Staff failed to follow medication administration policies, resulting in Tenant #1 receiving Tenant #2's medications, causing serious health consequences and an emergency room visit. Staff C was removed from medication duties due to these errors.
Violations (1)
67.2(3) The program failed to follow its established medication administration policies. Staff C administered the wrong medications to Tenant #1 and Tenant #2 on 10/8/24, leading to Tenant #1's accidental drug ingestion and hospitalization.
Report Facts
Fine amount: 3500
Inspection Report — Jul 17, 2024
Renewal
Date: Jul 17, 2024
Visit Reason
The inspection was a recertification visit conducted to determine compliance with certification rules for an Assisted Living Program.
Findings
The program failed to develop individualized service plans that adequately addressed the needs of 5 of 9 tenants reviewed, specifically lacking clear specifications on the frequency of required frequent checks and dietary needs.
Violations (1)
Failed to develop service plans to adequately address the needs of 5 of 9 tenants reviewed, including unclear frequency of frequent checks and missing dietary needs documentation.
Report Facts
Number of tenants without cognitive impairment: 86
Number of tenants with cognitive impairment: 6
Tenants reviewed for service plans: 9
Tenants with deficient service plans: 5
Resident charts audited per month: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN | Confirmed deficiencies in service plans regarding frequent checks and dietary needs | |
| Health Services Director (HSD) | Conducted chart audits and received education regarding documentation of resident individualized needs | |
| Assistant Health Service Director (AHSD) | Conducted chart audits and received education regarding documentation of resident individualized needs | |
| Executive Director (ED) | Responsible for quarterly audits to ensure service plans reflect specific requirements | |
| Director | Indicated unawareness of Tenant #3's dietary physician order |
Inspection Report — May 29, 2024
Complaint Investigation
Date: May 29, 2024
Visit Reason
The inspection was conducted as an investigation of Incident #120325-I and Complaints #118969-C and #121089-C.
Complaint Details
Investigation of Incident #120325-I, Complaint #118969-C, and Complaint #121089-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the incident and complaints.
Report Facts
Number of tenants without cognitive impairment: 82
Number of tenants with cognitive impairment: 8
Inspection Report — Jun 27, 2023
Complaint Investigation
Date: Jun 27, 2023
Visit Reason
The inspection was conducted as part of an investigation of Complaint #108982-C regarding regulatory compliance related to tenant records retention.
Complaint Details
The visit was complaint-related, investigating Complaint #108982-C. The complaint was substantiated as the program did not retain tenant records for the required minimum of three years.
Findings
The program failed to retain all tenant records for a minimum of three years after transfer or death, specifically for one tenant whose records were destroyed after 90 days contrary to regulations.
Violations (1)
Failure to retain all records pertaining to the tenant for a minimum of three years after the transfer or death of the tenant.
Report Facts
Tenants without cognitive impairment: 82
Tenants with cognitive impairment: 3
Retention period for task sheets: 90
Corrective action completion date: Jun 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Care Services Manager | Interviewed and confirmed destruction of task sheets every 90 days | |
| Administrator | Confirmed not all tenant records were retained for minimum three years | |
| Director of Nursing | Made aware of correct record retention procedures and involved in training | |
| Assistant Director of Nursing | Trained on correct procedure for tenant records retention | |
| Former Regional Operations Manager | Informed staff that task sheets should be kept for 90 days then destroyed |
Inspection Report — Oct 12, 2022
Complaint Investigation
Date: Oct 12, 2022
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #105277-C and #100126-I, and to revisit and determine progress toward correcting deficiencies identified during investigations of Mandatory Reports #97518-M and #97371-M.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #105277-C & 100126-I. The deficiency cited was a re-citation from previous mandatory reports.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints. However, a regulatory insufficiency was re-cited for failure to complete Department of Human Services (DHS) evaluations for 5 staff members with criminal histories. The Director confirmed DHS evaluations were not initiated due to lack of training but committed to immediate action.
Violations (1)
Failure to complete an evaluation by the Department of Human Services (DHS) for 5 staff members with criminal history prior to employment.
Report Facts
Number of tenants without cognitive impairment: 78
Number of tenants with cognitive impairment: 2
Number of staff with missing DHS evaluations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in deficiency for missing DHS evaluation | |
| Staff B | Named in deficiency for missing DHS evaluation | |
| Staff C | Named in deficiency for missing DHS evaluation | |
| Staff D | Named in deficiency for missing DHS evaluation | |
| Staff E | Named in deficiency for missing DHS evaluation | |
| Executive Director | Executive Director | Completed and submitted criminal history forms to DHS and conducted audits |
| Regional Executive Director | Regional Executive Director | Trained Executive Director and Administrative Specialist on hiring process |
Inspection Report — Oct 10, 2022
Enforcement
Date: Oct 10, 2022
Visit Reason
Revisit investigations of complaints #97518-M and #97371-M were conducted from 10/10/22 to 10/12/22 to determine compliance with employment evaluation requirements.
Complaint Details
Revisit Investigations #97518-M & 97371-M
Findings
The program failed to complete Department of Human Services evaluations for five staff members with criminal histories, despite their continued employment during the investigation period.
Violations (1)
IAC 481-67.19(5) Employment prohibition: The program did not complete DHS evaluations for five staff members with criminal histories before or during their employment as of 10/12/22.
Report Facts
Fine amount: 500
Inspection Report — Aug 17, 2021
Complaint Investigation
Date: Aug 17, 2021
Visit Reason
The inspection was conducted as a result of investigations of Mandatory Reports #97518-M and #97371-M regarding regulatory insufficiencies.
Complaint Details
The visit was complaint-related based on investigations of Mandatory Report #97518-M and Mandatory Report #97371-M. The deficiency was substantiated by interviews and record reviews confirming the failure to ensure appropriate background checks for agency staff.
Findings
The program failed to ensure that 2 of 2 staff hired through staffing agencies had background checks completed by the Single Contact Repository or by a combination of the Department of Public Safety and the Department of Human Services, as required.
Violations (1)
Failure to ensure background checks were completed using the Single Contact Repository or required combination for 2 staff hired through staffing agencies.
Report Facts
Number of tenants without cognitive disorder: 53
Number of tenants with cognitive disorder: 4
Staff with missing required background checks: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Named in finding for missing required background check | |
| Staff K | Named in finding for missing required background check | |
| Executive Director | Executive Director | Removed Staff I and Staff K from providing services until background checks were completed; involved in corrective actions and audits |
| Interim Director | Confirmed findings during interview | |
| Care Services Manager | Confirmed findings during interview | |
| RDCS | Provided re-education to Executive Director on required background checks |
Inspection Report — Aug 2, 2021
Renewal
Date: Aug 2, 2021
Visit Reason
The inspection was a recertification conducted to determine compliance with certification for an Assisted Living Program, including an onsite infection control survey.
Findings
The facility was found deficient in staffing procedures related to emergency response for tenants with cognitive disorders and in maintaining buildings and grounds in a clean, safe, and sanitary condition. Specific issues included failure to follow written procedures for emergency pendant response and inadequate housekeeping services resulting in unclean tenant apartments and common areas.
Violations (2)
Failed to follow a system, program, or written staff procedure to address the Program's response to the emergency needs of tenants with cognitive disorder.
Failed to ensure all buildings and grounds were kept well-maintained, clean, safe and sanitary, including stained apartment flooring, unclean garbage disposal closets, and inadequate housekeeping services.
Report Facts
Number of tenants without cognitive disorder: 53
Number of tenants with cognitive disorder: 4
Pendant call response time: 49084
Housekeeping audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Evaluated residents and determined no unmet needs; involved in re-education and monitoring of emergency response and housekeeping | |
| Regional Director of Care Services | Re-educated Care Service Manager on emergency response procedures | |
| Care Service Manager | Re-educated on emergency response procedures and housekeeping procedures | |
| Interim Director | Confirmed findings related to housekeeping and emergency response | |
| Staff A | Interviewed regarding pendant system and housekeeping duties | |
| Staff D | Interviewed regarding pendant call response and housekeeping duties | |
| Staff E | Interviewed regarding housekeeping staffing and tenant complaints | |
| Maintenance Technician | Conducted observational audit of building and grounds with Executive Director |
Inspection Report — Jul 26, 2021
Enforcement
Date: Jul 26, 2021
Visit Reason
This citation was issued following investigations 97518-M and 97371-M conducted between July 26, 2021 and August 17, 2021 regarding background check compliance for staff hired through staffing agencies.
Complaint Details
Investigations 97518-M and 97371-M
Findings
The program failed to ensure that two staff hired through staffing agencies had background checks completed by the Single Contact Repository or by the required combination of the Department of Public Safety and the Department of Human Services. The staffing agencies used other background check services not compliant with Iowa requirements.
Violations (1)
IAC 481-67.19(3)b Conducting a background check: The program failed to ensure that two staff hired through staffing agencies had background checks completed by the Single Contact Repository or by the Department of Public Safety and Department of Human Services. The staffing agencies used noncompliant background check services.
Report Facts
Fine amount: 500
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