Inspection Reports for Allen Place Senior Living
1406 E 19th St, Atlantic, IA 50022, United States, IA, 50022
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Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 6
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.
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.
Complaint Details
The visit was complaint-related, investigating multiple complaints and an incident involving Tenant C1's fall and injury.
Deficiencies (6)
| Description |
|---|
| 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
Total census: 36
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
Renewal
Census: 36
Deficiencies: 2
Nov 7, 2024
Visit Reason
The visit was conducted as a recertification inspection to determine compliance with certification rules for an Assisted Living Program.
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.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaints #118038-C and 123706-C.
Deficiencies (2)
| Description |
|---|
| 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
Total census: 36
Staff reviewed for background check compliance: 2
Tenants reviewed for service plans: 4
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 1
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.
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.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint 105369-C. The deficiency cited was related to Incident #108571-I.
Deficiencies (1)
| Description |
|---|
| 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
Total census: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in deficiency for not receiving required nurse delegation training within 30 days of employment |
Inspection Report
Renewal
Census: 38
Deficiencies: 2
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.
Deficiencies (2)
| Description |
|---|
| 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 |
Inspection Report
Renewal
Census: 42
Deficiencies: 4
Apr 23, 2019
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification visit; however, several deficiencies were noted related to staffing training, record checks, tenant evaluations, and service plans.
Deficiencies (4)
| Description |
|---|
| Program failed to ensure completion of nursing delegations within 30 days of employment for 3 of 4 staff reviewed. |
| Program failed to obtain evaluation from the Department of Human Services for 1 staff with a criminal history. |
| Program failed to complete functional, cognitive, and health evaluations with significant change for 1 of 2 tenants admitted to hospice. |
| Program failed to update tenants’ service plans after significant change for 1 of 2 tenants admitted to hospice. |
Report Facts
Number of tenants without cognitive disorder: 39
Number of tenants with cognitive disorder: 3
Total Population of Program at time of on-site: 42
Staff reviewed for nursing delegation training: 4
Staff lacking delegation training within 30 days: 3
Staff reviewed with criminal history evaluation: 1
Tenants admitted to hospice reviewed for evaluations and service plans: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sammarra Smith | Executive Director | Signed Plan of Correction letter |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Feb 14, 2018
Visit Reason
The visit was conducted to investigate complaints #73458-C and #73480-C at the assisted living program.
Findings
The investigation of the complaints resulted in no regulatory insufficiencies cited. The program met criteria to be an Assisted Living Program for People with Dementia for the last two recertification visits.
Complaint Details
Complaints #73458-C and #73480-C were investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 30
Number of tenants with cognitive disorder: 9
Total Census: 39
Inspection Report
Renewal
Census: 44
Deficiencies: 4
Apr 5, 2017
Visit Reason
A recertification visit was conducted to determine compliance with certification for an Assisted Living Program. In addition to the recertification visit, Complaint #66805-C was investigated.
Findings
The inspection identified regulatory insufficiencies related to tenant rights, record checks, service plans, and food service. Specific issues included tenant safety concerns, incomplete criminal background checks for staff, inadequate service plans for tenants, and lack of current food protection training for staff.
Complaint Details
Complaint #66805-C was investigated during the recertification visit. Tenant #2 was moved to a Memory Care Center as planned. Resident Council Meetings and quarterly assessments were planned to address safety concerns. No other residents were found to have wandering, intrusive behaviors after review.
Deficiencies (4)
| Description |
|---|
| Program failed to ensure all tenants treated with consideration, respect and full recognition of personal dignity and autonomy regarding their safety. |
| Program failed to complete a criminal history background check and abuse checks prior to employment for 1 of 6 staff files reviewed. |
| Program failed to develop service plans to indicate tenants' identified needs for 2 of 5 tenant files reviewed. |
| Program failed to have anyone responsible for food preparation complete a state approved food protection program. |
Report Facts
Census: 44
Number of tenants without cognitive disorder: 38
Number of tenants with cognitive disorder: 6
Staff files reviewed: 6
Tenant files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Richter | Executive Director | Named in Plan of Correction letter as Executive Director of Allen Place |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Mar 22, 2016
Visit Reason
The inspection was conducted as a complaint/incident investigation following a report that Tenant #1 fell and died from a head injury at Allen Place.
Findings
The investigation found no regulatory insufficiencies. Tenant #1 had a recent medication change causing dizziness, fell independently, and died six days later from head bleeding. No previous concerns of dizziness or falls were noted.
Complaint Details
Allegation: Staffing - Tenant #1 fell and died from a head injury. Findings were not substantiated. Tenant #1 had no cognitive impairment but had increased medication dosage prior to fall. Incident report documented dizziness complaint. Tenant #1 was hospitalized and died six days after the fall.
Report Facts
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 6
Total Population of Program at time of on-site: 34
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 4
Jun 3, 2015
Visit Reason
The inspection was conducted as a Final Initial Certification Monitoring Evaluation and Complaint/Incident Investigation following complaints related to medication management and tenant rights at Allen Place, Atlantic, Iowa.
Findings
No regulatory insufficiencies were found related to medication management or tenant rights complaints. However, regulatory insufficiencies were cited in staffing, evaluation of tenants, service plans, and nurse review during the initial certification and complaint investigations.
Complaint Details
Allegations of Medication Management and Tenant Rights were investigated and found to be unsubstantiated based on interviews and record reviews.
Deficiencies (4)
| Description |
|---|
| Staffing: Program's registered nurse did not ensure staff were trained and competent within 30 days of employment. |
| Evaluation of Tenant: Evaluations were not completed within 30 days of admission or with significant change; functional evaluations were incomplete. |
| Service Plans: Service plans were not based on evaluations and did not meet specific tenant needs. |
| Nurse Review: Nurse reviews were not completed with significant changes in tenant condition. |
Report Facts
Census: 33
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 6
Personnel files reviewed: 5
Tenant files reviewed: 5
Medication administration documented: 25
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