Inspection Reports for Addington Place of Clinton
1701 13th Ave N, Clinton, IA 52732, United States, IA, 52732
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 20, 2025, cited a deficiency for failure to ensure evaluations were completed by the Department of Health and Human Services for staff with criminal histories prior to employment. Earlier inspections showed a recurring issue with incomplete background evaluations for staff and some concerns related to tenant care, safety checks, and training. Complaint investigations substantiated problems such as tenant elopement due to unlocked doors and inadequate staff training, while other complaints were unsubstantiated. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The inspection history indicates ongoing challenges with staff background evaluations and training, with some improvement in addressing care and safety concerns over time.
Deficiencies (last 14 years)
Deficiencies (over 14 years)
3.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
11% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
64 residents
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 64
Deficiencies: 1
Date: May 20, 2025
Visit Reason
The visit was a follow-up inspection related to a previous regulatory insufficiency cited on 11/4/24 regarding employment record checks.
Findings
The program failed to ensure that evaluations by the Department of Health and Human Services were completed for staff with criminal histories prior to employment. Specifically, two staff members (Staff A and Staff C) were employed without completed evaluations as required.
Deficiencies (1)
Failure to ensure evaluations were completed by the Department of Health and Human Services for staff with criminal history prior to employment.
Report Facts
Number of tenants without cognitive impairment: 44
Number of tenants with cognitive impairment: 20
Total census: 64
Number of staff with background checks requiring further action: 2
Evaluation approval date for Staff A: May 21, 2025
Evaluation approval date for Staff C: May 22, 2025
Compliance date for plan of correction: Jun 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Staff member with criminal history background check requiring evaluation not completed prior to employment | |
| Staff C | Staff member with criminal history background check requiring evaluation not completed prior to employment |
Inspection Report
Plan of Correction
Census: 64
Deficiencies: 1
Date: Nov 4, 2024
Visit Reason
The visit was a revisit conducted to determine progress in correcting regulatory insufficiencies cited during the recertification visit completed on 2024-05-16.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #122851-C, Incident #122709-I, or the revisit of #122196-M.
Findings
No regulatory insufficiencies were cited during the investigation of Complaint #122851-C, Incident #122709-I, or the revisit of #122196-M. However, a regulatory insufficiency was cited for failure to ensure evaluations were completed by the Department of Health and Human Services for 4 staff with criminal or founded child abuse history.
Deficiencies (1)
The program failed to ensure evaluations were completed by the Department of Health and Human Services for 4 of 4 staff reviewed with a criminal or founded child abuse history.
Report Facts
Number of tenants without cognitive impairment: 48
Number of tenants with cognitive impairment: 16
Total census: 64
Number of staff with incomplete evaluations: 4
Plan of correction completion date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Staff with criminal history whose evaluation was not completed before working | |
| Staff C | Staff with criminal history whose evaluation was not completed before working | |
| Staff D | Staff with history of child abuse whose evaluation was not completed before working | |
| Staff E | Staff with criminal history whose evaluation was not completed before working | |
| Executive Director | Executive Director | Confirmed findings and responsible for corrective actions |
| Business Office Manager | Business Office Manager | Responsible for conducting background checks and maintaining compliance |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 2
Date: Jul 24, 2024
Visit Reason
The inspection was conducted as an investigation of Mandatory Report #122196-M concerning the care and safety of tenants at the assisted living program.
Complaint Details
The visit was triggered by a complaint (Mandatory Report #122196-M) regarding the safety and care of Tenant #1 who eloped from the facility through an unlocked courtyard door. The complaint was substantiated based on findings of staff negligence and failure to follow training protocols.
Findings
The investigation found that staff failed to provide services in accordance with nurse delegated training, resulting in a tenant eloping through an unlocked courtyard door. Additionally, staff failed to complete required safety checks and dependent adult abuse training documentation was missing for one staff member.
Deficiencies (2)
Program staff failed to provide services in accordance with nurse delegated training, affecting one tenant who eloped due to unlocked doors and incomplete safety checks.
Program failed to provide documentation that one staff member had completed required dependent adult abuse training.
Report Facts
Number of tenants without cognitive impairment: 36
Number of tenants with cognitive impairment: 13
Total census: 49
Temperature on incident day: 81
Wind speed on incident day: 13
Safety checks required per shift: 8
Staff hire date: Aug 11, 2021
Staff hire date: Mar 1, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in findings related to failure to re-lock courtyard door and incomplete door alarm responses | |
| Staff B | Care Manager | Named in findings related to failure to complete safety checks, door alarm responses, and lack of dependent adult abuse training documentation |
| Executive Director | Conducted internal investigation after tenant elopement and provided multiple interviews | |
| Healthcare Coordinator | Involved in investigation and interviews regarding tenant elopement and staff performance | |
| Director of Celebrations | Confirmed staff actions related to courtyard door unlocking during tenant activities |
Inspection Report
Renewal
Census: 45
Deficiencies: 2
Date: May 16, 2024
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program for People with Dementia.
Findings
Two regulatory insufficiencies were cited: failure to provide adequate care for one tenant with dementia, evidenced by unaddressed weight loss and inadequate meal service; and failure to complete employee background checks prior to hire for three employees.
Deficiencies (2)
Failure to provide adequate care for Tenant #2, including failure to address a 10% weight loss and inappropriate meal service.
Failure to ensure employee background checks were completed prior to hire for 3 of 10 employees reviewed (Staff A, Staff B, and Staff C).
Report Facts
Census: 45
Weight loss percentage: 10
Number of employees without prior background checks: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Hired on 12/12/23 without completed background check | |
| Staff B | Hired on 4/10/24 without completed background check | |
| Staff C | Hired on 3/07/24 without completed background check | |
| Executive Director/Registered Nurse | Executive Director/Registered Nurse | Interviewed regarding unaddressed weight loss and background check issues |
| Licensed Practical Nurse | Licensed Practical Nurse | Interviewed regarding unaddressed weight loss |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 2
Date: Dec 12, 2022
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #107142-C, with prior complaints #109394-C, #106894-C and Incident #104713-I also reviewed.
Complaint Details
The visit was complaint-related for Complaint #107142-C. No regulatory insufficiencies were cited for Complaints #109394-C, #106894-C or Incident #104713-I.
Findings
No regulatory insufficiencies were found for complaints #109394-C, #106894-C, or Incident #104713-I. Deficiencies were cited for Complaint #107142-C including failure to have an activity calendar available to all tenants, and failure to maintain one tenant's apartment carpeting in a safe and well-maintained condition.
Deficiencies (2)
Failed to have an activity calendar available to all tenants in the building, specifically in the memory care unit.
Failed to ensure one tenant apartment was well maintained and safe due to large tears in carpeting that posed a safety risk.
Report Facts
Number of tenants without cognitive impairment: 26
Number of tenants with cognitive impairment: 10
Total census: 36
Length of carpet tear: 2.5
Width of carpet tear: 2.5
Duration of carpet tear: 4.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Interviewed regarding lack of activity calendar and activity programming in memory care unit | |
| Activity Director | Interviewed about activity calendars and programming in memory care unit | |
| Director | Confirmed findings regarding activity calendar and carpet condition; provided information on repair plans |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Date: Oct 10, 2022
Visit Reason
The inspection was conducted to investigate multiple complaints and an incident (104472-M) related to the assisted living program for people with dementia.
Complaint Details
The investigation included complaints 104480-A, 104479-A, 104476-A, 104477-A, 104621-A which found no regulatory insufficiencies. The incident 104472-M was substantiated with a finding of failure to train contracted staff.
Findings
No regulatory insufficiencies were found related to the complaints investigated, but a regulatory insufficiency was cited for failure to provide appropriate training to one contracted employee (Staff A) as evidenced by an incident involving improper toileting assistance.
Deficiencies (1)
Failure to provide training to 1 of 1 contracted employees reviewed (Staff A) appropriate to assigned tasks and target population.
Report Facts
Census: 46
Number of tenants without cognitive disorder: 29
Number of tenants with cognitive disorder: 6
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 11
Agency staffing last used: Jun 29, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Contracted Employee | Named in finding for failure to receive appropriate training |
| Staff B | Witnessed and reported improper toileting assistance by Staff A | |
| RN Regional Nurse Specialist | RN Regional Nurse Specialist | Prepared statement and confirmed findings |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 5
Date: May 18, 2022
Visit Reason
The inspection was conducted as an investigation into Complaints #104609-C and #103783-C regarding tenant care and services at Prairie Hills at Clinton.
Complaint Details
The visit was triggered by complaints #104609-C and #103783-C. The investigation substantiated issues with tenant care, staffing, and service plan compliance.
Findings
The investigation found multiple deficiencies including inadequate care and services related to tenant belongings, insufficient staffing to meet tenant needs, retention of tenants requiring two-person assistance, retention of tenants displaying unmanageable aggression, and failure to update service plans as needed.
Deficiencies (5)
Failure to ensure appropriate care and services regarding belongings of tenants, including lost glasses, dentures, and laundry items.
Insufficient number of trained staff available to fully meet tenants' identified needs, including unsafe staffing levels on the memory care unit.
Retention of a tenant requiring routine two-person assistance with transfers, exceeding program's level of care.
Retention of a tenant displaying unmanageable physical aggression despite intervention.
Failure to update service plans as needed for tenants, including lack of interventions for shower refusals, removal of clothing, and changes in behavior.
Report Facts
Total census: 46
Unclaimed eyeglasses: 10
Safety check failures: 61
Pages of pendant activity report: 79
Pages with pendants answered under 15 minutes: 61
Discharge notice dates: 2
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 11
Date: Jan 3, 2022
Visit Reason
The inspection was conducted as a recertification visit and investigation of incidents and complaints (#97330-C, #97708-I, #101239-C) to determine if the assisted living program is in substantial compliance with certification rules for an Assisted Living Program for People with Dementia.
Complaint Details
The visit was complaint-related involving investigation of incidents and complaints #97330-C, #97708-I, and #101239-C. No regulatory insufficiencies were cited regarding Complaint #97330-C or the onsite infection control survey. The investigation focused on incidents involving tenants #5 and #6, including failure to complete incident reports and inadequate care.
Findings
The program was found to have multiple regulatory insufficiencies including failure to complete incident reports, inadequate tenant care and treatment, medication administration issues, insufficient staffing, lack of dementia-specific education for personnel, failure to ensure alarm system functionality, and deficient record checks. Several tenants experienced unsafe conditions and inadequate care. A plan of correction was submitted to address these deficiencies.
Deficiencies (11)
Program failed to complete incident reports for 2 of 6 tenants reviewed.
Program failed to provide adequate care and treatment to 1 of 5 tenants reviewed.
Program failed to ensure 4 of 9 staff reviewed completed a department-approved medication manager course prior to administering medication.
Program failed to administer medication as prescribed by primary care providers for multiple tenants.
Program failed to provide sufficient staff to meet tenant needs, affecting all tenants (census 48).
Program failed to document initial training for 5 of 8 newly hired staff to ensure competency.
Program failed to provide dependent adult abuse training to 2 of 8 employees reviewed.
Program failed to conduct background checks prior to hiring 2 of 8 employees.
Program failed to ensure service plans were updated as needed for 2 of 5 tenants reviewed.
Program failed to provide dementia-specific education within 30 days of hire to 8 employees reviewed.
Program failed to ensure alarm system was utilized on all exit doors affecting 1 tenant.
Report Facts
Total Census: 48
Tenants without cognitive disorder: 28
Tenants with cognitive disorder: 6
Memory Care Unit tenants without cognitive disorder: 0
Memory Care Unit tenants with cognitive disorder: 14
Staff interviewed in group: 17
Device Activity Report pages: 51
Emergency pendant calls not responded within 14 minutes: 165
Emergency pendant calls not responded within 27 minutes: 60
Emergency pendant calls not responded within 63 minutes: 14
Staff reviewed for dependent adult abuse training: 8
Staff lacking dependent adult abuse training: 2
Staff reviewed for background checks: 8
Staff hired without background checks: 2
Tenants reviewed for service plan updates: 5
Tenants with outdated service plans: 2
Employees reviewed for dementia-specific education: 8
Employees lacking dementia-specific education: 8
Tenants affected by alarm system failure: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy McAtee | Portfolio Leader, Interim Director | Signed the plan of correction and confirmed findings. |
| Staff D | Failed to complete medication manager course prior to administering medication; lacked dependent adult abuse training; involved in medication administration findings. | |
| Staff E | Failed to complete medication manager course prior to administering medication; lacked dementia-specific education; involved in medication administration findings. | |
| Staff F | Failed to complete medication manager course prior to administering medication; lacked dementia-specific education; involved in medication administration findings. | |
| Staff I | Failed to complete medication manager course prior to administering medication; lacked dementia-specific education; involved in medication administration findings. | |
| Staff J | Lacked dementia-specific education. | |
| Staff K | Lacked dependent adult abuse training and dementia-specific education; hired without background check. | |
| Staff G | Lacked dependent adult abuse training; hired without dementia-specific education. | |
| Staff C | Reported on tenant care and emergency pendant response; involved in tenant care findings. | |
| Staff A | Reported incidents involving tenants; involved in tenant care findings. | |
| Staff B | Reported tenant aggressive behavior and care issues. |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 4
Date: Jul 3, 2019
Visit Reason
The inspection was conducted as an incident and complaint visit to investigate regulatory insufficiencies related to tenant rights, staffing, service plans, and life safety at Prairie Hills at Clinton.
Complaint Details
The visit was triggered by complaints and incidents including multiple falls and inadequate care for tenants with dementia. No regulatory insufficiencies were cited during the investigation of Incident #83495-I, but deficiencies were cited during the investigation of Complaint #84025-C.
Findings
The inspection found multiple regulatory insufficiencies including failure to ensure adequate staffing on the locked memory care unit, inadequate documentation of visual checks for tenants at risk of falls, incomplete and outdated service plans for tenants, and a non-functioning operating alarm system connected to exit doors in the dementia-specific program.
Deficiencies (4)
Failure to ensure adequate staffing on the locked memory care unit, potentially affecting all 16 tenants.
Failure to provide individualized service plans addressing identified needs for 5 of 6 tenants reviewed.
Failure to ensure an operating alarm system connected to each exit door in the dementia-specific program.
Failure to document visual checks for tenants requiring safety checks 16 times per shift.
Report Facts
Census: 56
Tenants with cognitive disorder: 16
Tenants without cognitive disorder: 36
Tenants with cognitive disorder: 4
Staff checks required: 16
Tenants reviewed: 6
Tenants affected by staffing deficiency: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristin L Trotter | Manager | Signed the plan of correction and confirmed findings on 7/3/19 |
Inspection Report
Renewal
Census: 42
Deficiencies: 1
Date: Dec 4, 2018
Visit Reason
The recertification visit was conducted to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Findings
The program failed to develop individualized service plans reflecting tenants' identified needs and preferences for assistance, resulting in regulatory insufficiency related to service plans for three tenants reviewed.
Deficiencies (1)
Program failed to develop service plans that reflected the tenants' identified needs and preferences for assistance.
Report Facts
Number of tenants without cognitive disorder in general population: 26
Number of tenants with cognitive disorder in general population: 8
Number of tenants without cognitive disorder in memory care unit: 0
Number of tenants with cognitive disorder in memory care unit: 8
Total Census of Assisted Living Program for People with Dementia: 42
Number of tenants reviewed for deficiency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Trotter | Manager | Signed plan of correction letter |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 0
Date: Jun 21, 2018
Visit Reason
The inspection was conducted as an investigation of incident #75358-I and complaints #76310-C, #76307-C, and #76315-C at the assisted living program for people with dementia.
Complaint Details
Investigation of incident #75358-I and complaints #76310-C, #76307-C, and #76315-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 disorder in general population: 45
Number of tenants with cognitive disorder in general population: 6
Number of tenants without cognitive disorder in memory care unit: 0
Number of tenants with cognitive disorder in memory care unit: 13
Total census of assisted living program for people with dementia: 64
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 0
Date: Aug 30, 2017
Visit Reason
The inspection was conducted as an investigation of two incidents, #69076-I and #68778-I, related to the assisted living program.
Complaint Details
Investigation of Incident #69076-I and Incident #68778-I found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the two incidents.
Report Facts
Number of tenants without cognitive disorder: 50
Number of tenants with cognitive disorder: 18
Total population of Program at time of on-site: 68
Inspection Report
Renewal
Census: 72
Deficiencies: 3
Date: Nov 29, 2016
Visit Reason
The visit was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited regarding the investigation of Incident #64132-I. However, deficiencies were found related to record checks, service plans, and dementia-specific education for personnel.
Deficiencies (3)
The program failed to have an evaluation from the Department of Human Services completed prior to hire to determine whether the crime warranted prohibition of employment for one of seven staff reviewed.
The program failed to develop service plans that reflected the identified needs of the tenants for two of seven tenant files reviewed, including incomplete documentation of treatment and care plans.
The program failed to have staff complete eight hours of dementia-specific education and training within 30 days of employment for three of seven staff reviewed.
Report Facts
Number of tenants without cognitive disorder: 62
Number of tenants with cognitive disorder: 10
Total Population of Program at time of on-site: 72
Staff reviewed: 7
Tenants reviewed: 7
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 5
Date: Oct 14, 2015
Visit Reason
The inspection was conducted as a complaint and incident investigation related to multiple complaint intake numbers regarding regulatory insufficiencies and allegations of dependent adult abuse at Prairie Hills at Clinton.
Complaint Details
The complaint investigation involved allegations of dependent adult abuse and regulatory insufficiencies related to incidents involving tenants #1, #2, #3, #4, and #5. Findings for all allegations were unsubstantiated except for regulatory insufficiencies cited during the investigation.
Findings
The investigation found regulatory insufficiencies related to program policies and procedures, staffing, nurse review, and structural requirements. Specific incidents involved failure to follow policies on incident reports and medication administration, inadequate staffing, failure to assess and document health status, and unsafe structural conditions allowing a tenant to elope.
Deficiencies (5)
Program failed to follow policies and procedures regarding incident reports and medication administration for Tenant #2.
Insufficient number of trained staff available at all times to meet tenants' identified needs, resulting in injury to Tenant #1.
Failure to assess and document health status of tenants, including nurse reviews not completed every 90 days for three of five tenant files reviewed.
Failure to provide staff communication in writing occurrences that differed from tenants' normal health, functional and cognitive status.
Structural deficiencies: buildings and grounds not well-maintained, clean, safe and sanitary; courtyard gates not secured allowing tenant elopement.
Report Facts
Census: 72
Civil penalty amount: 2500
Reduction of civil penalty: 1625
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in findings related to assisting Tenant #1 in wheelchair and medication administration | |
| Rose Boccella | Program Coordinator | Contact person for the program regarding the report and plan of correction |
| Jim Friberg | Bureau Chief, Adult Services Bureau | Signed the demand letter |
Inspection Report
Monitoring
Census: 74
Deficiencies: 0
Date: Nov 18, 2014
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were found during this evaluation. The review of recertification documents was completed and accepted, including the State Fire Marshal's inspection and Facility Engineer's approval of evacuation plans.
Report Facts
Census: 74
Population without cognitive disorder: 62
Population with cognitive disorder: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator, Adult Services Bureau | Signed the Final Recertification Monitoring Evaluation Report |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
Date: Mar 11, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding allegations that the assisted living program did not serve tenants enough food during meals, did not serve palatable meals, and did not offer alternate food items or refused to give alternate food items when requested.
Complaint Details
The complaint alleged insufficient food servings, unpalatable meals, and lack of alternate food options. The monitor observed meal services on March 11 and 12, 2013, interviewed 15 tenants, and reviewed food temperature logs and menus. Tenants generally reported satisfaction with food quality and quantity. No regulatory insufficiencies were identified.
Findings
The investigation found no regulatory insufficiencies. Observations noted that meals were served restaurant style with appropriate portions and palatable food. Tenant interviews indicated general satisfaction with food quantity and quality. Food temperature logs showed all hot foods exceeded required temperatures prior to serving. No deficiencies were cited.
Report Facts
Total census: 81
Tenants interviewed: 15
Complaint/Incident Investigation Dates: March 11 and 12, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Signed the cover letter for the complaint/incident investigation report |
| Maribeth Freland | RN | Monitor who conducted the complaint/incident investigation |
| Jean Greeley | Administrator | Administrator of Prairie Hills at Clinton, named in the report |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Date: Aug 15, 2012
Visit Reason
The inspection was conducted as an amended final recertification and complaint/incident investigation following a report of missing Vicodin tablets from a tenant's prescription bottle.
Complaint Details
The complaint involved one tenant missing 81 tablets of Vicodin from a locked cupboard accessible only by staff. The program conducted a timely investigation and reported the missing medications to the Department of Inspections and Appeals. No regulatory insufficiency was found related to medication management.
Findings
The investigation found a discrepancy of 81 missing Vicodin tablets from Tenant #2's medication, with no regulatory insufficiencies noted related to medication administration. A life safety deficiency was identified due to an unsecured courtyard door alarm system in the dementia-specific program.
Deficiencies (1)
An operating alarm system shall be connected to each exit door in a dementia-specific program; the alarm system was disconnected allowing free access to the courtyard and risk of elopement.
Report Facts
Number of tenants without cognitive disorder: 63
Number of tenants with cognitive disorder: 8
Total census: 71
Missing Vicodin tablets: 81
Date of complaint/incident investigation: Aug 15, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Signed letter regarding the amended final recertification and complaint/incident investigation report |
| Maribeth Freland | RN | Monitor during complaint/incident investigation |
| Joyce Kix | RN | Monitor during complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 1
Date: Sep 6, 2011
Visit Reason
The inspection was conducted as a complaint/incident investigation following allegations related to tenant incidents and regulatory insufficiencies at Prairie Hills at Clinton.
Complaint Details
The complaint investigation was substantiated with findings of regulatory insufficiency related to tenant evaluations. Incident reports were reviewed and found to be consistently documented with no noted regulatory insufficiencies.
Findings
The investigation reviewed tenant files and incident reports, finding multiple incidents involving tenant falls and injuries. The program had regulatory insufficiencies in evaluating tenants' functional, cognitive, and health status within required timeframes. However, no regulatory insufficiencies were noted regarding incident reporting documentation.
Deficiencies (1)
Failure to evaluate each tenant’s functional, cognitive, and health status within 30 days of occupancy and as needed thereafter.
Report Facts
Number of tenants without cognitive disorder in general population: 61
Number of tenants with cognitive disorder in general population: 3
Total population of general program: 64
Number of tenants without cognitive disorder in dementia-specific program: 3
Number of tenants with cognitive disorder in dementia-specific program: 4
Total population of dementia-specific program: 7
Total census of Assisted Living Program: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | MA | Monitor for complaint/incident investigation |
| Margaret Kaltefleiter | RN MS | Monitor for complaint/incident investigation |
| Jean Greeley | Administrator | Named in relation to review of incident reports and regulatory insufficiency |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 5
Date: Dec 21, 2010
Visit Reason
A complaint investigation on-site visit was conducted at Prairie Hills Assisted Living on December 21 and 22, 2010, to investigate allegations and review regulatory compliance including a complaint and incident investigation.
Complaint Details
Complaint Intake #31879-I and 31857-C involved allegations of medication administration errors and an incident where a staff member was observed slapping a tenant and making inappropriate comments. The incident was investigated and found not to be abuse but unprofessional conduct.
Findings
The investigation found regulatory insufficiencies related to individualized service plans, medication administration, and staffing training and delegation. An incident allegation of inappropriate staff interaction was determined not to be abuse. The program did not receive any regulatory insufficiencies during the certification period.
Deficiencies (5)
The service plan lacked individualized updates for staff interventions for tenant behaviors.
The service plan failed to document needed care for a pacemaker insertion site and failed to identify interventions for specific tenant needs.
Medication administration was not properly observed; staff did not ensure tenants swallowed medications and documentation errors were found in medication administration records.
The program failed to ensure all direct care staff received training and delegation by the current Registered Nurse.
A staff member was observed slapping a tenant and making inappropriate comments; investigation found the interaction was unprofessional but not abusive.
Report Facts
Current number of tenants without cognitive disorder: 49
Current number of tenants with cognitive disorder: 4
Total Population of General Population Program: 53
Total Population of Dementia Specific Program: 9
Total Census of Assisted Living Program: 62
Tenant satisfaction meeting attendees: 13
Certified nursing/medication assistants employed: 13
Universal Workers employed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jean Greeley | Administrator | Administrator of Prairie Hills Assisted Living named in report |
| Joyce Kix | RN | Monitor during investigation |
| Lori Miner | RN BSN | Monitor during investigation |
| Staff #9 | Certified medication aide (CMA) | Named in medication administration observation |
Inspection Report
Monitoring
Census: 63
Deficiencies: 10
Date: Aug 13, 2008
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to assess regulatory insufficiencies in tenant evaluation, service plan, medication, food service, and life safety at Prairie Hills Assisted Living in Clinton, IA.
Findings
The report found multiple regulatory insufficiencies including inconsistent tenant evaluations, incomplete cognitive assessments, inadequate service plan updates, medication administration issues, lack of food service training, and safety concerns regarding building security. A $500 civil penalty was assessed and the Plan of Correction was accepted.
Deficiencies (10)
The program did not consistently evaluate each tenant's functional, cognitive, and health status as needed.
The program did not complete a cognitive evaluation within 30 days as required.
The program did not update the service plan as needed by a multidisciplinary team.
The program did not consistently develop individualized service plans based on evaluations.
The program did not individualize service plans for tenants unable to plan their own activities.
Medications were not consistently given or documented as administered.
The administration of medications was not always provided by licensed or authorized personnel.
Staff did not have annual in-service training on food protection.
The program did not provide orientation and annual training on sanitation and safe food handling.
The building was not consistently safe; unsecured chemicals and open doors to laundry room were observed.
Report Facts
Civil penalty amount: 500
Current number of tenants without cognitive disorder: 45
Current number of tenants with cognitive disorder: 10
Total population in General Population Program: 55
Current number of tenants in Dementia Specific Program: 8
Total population in Dementia Specific Program: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jean Greeley | Administrator | Named as facility administrator in report |
| Lincoln Newsom | RN Monitor | Monitor conducting the evaluation |
| Stephanie Cummins | SW MA Monitor | Monitor conducting the evaluation |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed conclusion letter regarding penalty and plan of correction |
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