Inspection Report Summary
The most recent inspection on June 26, 2025, found no deficiencies during the complaint investigation. Earlier inspections showed a pattern of deficiencies related mainly to discharge documentation, service plan updates, tuberculosis screening, and medication management. Complaint investigations were mostly unsubstantiated, with one substantiated case involving failure to update a resident’s service plan after elopement incidents. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record shows some improvement over time, with fewer deficiencies noted in the most recent investigations compared to earlier years.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
48% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 26, 2025
Visit Reason
Investigation into complaints #127474-C, #127626-C and incidents #128463-I and #129044-I.
Findings
No deficiencies were cited during the investigation of the complaints and incidents.
Complaint Details
Investigation into Complaint #127474-C, Complaint #127626-C, Incident #128463-I and Incident #129044-I found no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 3
Mar 20, 2025
Visit Reason
The inspection was conducted as an investigation of Complaint #123569-C regarding the facility's discharge and transfer procedures.
Findings
The facility failed to provide proof that appropriate records accompanied a discharged resident and failed to document the disposition of personal property and medications for discharged residents, as confirmed by the Administrator.
Complaint Details
Investigation of Complaint #123569-C revealed failures in discharge record transfer and documentation of disposition of personal property and medications.
Deficiencies (3)
| Description |
|---|
| Facility failed to show proof the appropriate record was sent with the resident upon discharge for 1 of 3 discharged residents reviewed (Resident C2). |
| Facility failed to document the disposition of personal property upon discharge for 1 of 3 discharged residents (Resident C1). |
| Facility failed to document the disposition of medications for 2 of 3 discharged residents (Resident C1, Resident C2). |
Report Facts
Discharged residents reviewed: 3
Residents with missing discharge record proof: 1
Residents with missing personal property disposition documentation: 1
Residents with missing medication disposition documentation: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed findings regarding missing discharge documentation and record transfer. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 20, 2024
Visit Reason
Investigation of Incident #118054-I.
Findings
No deficiencies were cited during the investigation of Incident #118054-I.
Complaint Details
Investigation of Incident #118054-I found no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 5, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to incidents involving Resident #1, specifically regarding failure to update the resident's service plan following incidents of elopement.
Findings
The facility failed to modify the service plan for Resident #1 to reflect changes in behavior after two elopement incidents on 9/25/23 and 10/25/23. The service plan dated 6/15/23 did not include the history of elopement, and staff confirmed the plan was not updated accordingly.
Complaint Details
Investigation of Incident #116619-I found the deficiency related to failure to update the service plan for Resident #1 after elopement incidents. No deficiencies were cited for Incident #117033-I and Incident #116620-I.
Deficiencies (1)
| Description |
|---|
| Failure to modify service plans as needs changed for Resident #1, specifically not updating the service plan to reflect recent elopement behaviors. |
Report Facts
Incident dates: Elopement incidents occurred on 2023-09-25 and 2023-10-25
Admission date: Resident #1 admission date was 2023-06-15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Program Coordinator | Stated Resident #1's service plan was not updated to reflect recent behaviors of elopement | |
| Provisional Administrator | Confirmed the finding that the service plan was not updated |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 20, 2023
Visit Reason
Investigation into Incident #114348-I.
Findings
No deficiencies were cited during the investigation.
Complaint Details
Investigation into Incident #114348-I found no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 5
Jul 10, 2023
Visit Reason
The inspection was conducted to investigate complaints #112693-C, #111900-C, and incident #112455-I, and to determine compliance with licensing rules for a Residential Care Facility.
Findings
The facility was found non-compliant in several areas including failure to complete baseline tuberculosis (TB) screenings for personnel, failure to document resident condition at discharge for 2 of 4 former residents, failure to obtain physician orders for self-administration of insulin for one resident, failure to follow physician's special diet orders for one resident, and failure to complete the two-step TB test for 3 of 5 employees hired since February 2022.
Complaint Details
Investigation involved complaints #112693-C, #111900-C, and incident #112455-I. No deficiencies were cited during the investigation into these complaints, but deficiencies were cited during the survey conducted to determine compliance.
Deficiencies (5)
| Description |
|---|
| Facility failed to complete baseline TB screenings for personnel as required by Iowa Administrative Code 481 - Chapter 59. |
| Facility failed to document condition at discharge for 2 of 4 former residents reviewed. |
| Facility failed to obtain orders from primary care provider for self-administration of insulin for 1 insulin-dependent diabetic resident. |
| Facility failed to follow physician's orders for a special diet for 1 resident. |
| Facility failed to complete the two-step TB test for 3 of 5 employees hired since February 2022. |
Report Facts
Employees missing baseline TB screening: 3
Former residents missing discharge documentation: 2
Residents reviewed for special diet: 2
Insulin-dependent diabetic residents reviewed: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Hired 3/6/23; missing completion of two-step TB test. | |
| Staff D | Hired 2/18/22; missing completion of two-step TB test. | |
| Staff E | Hired 3/21/22; missing completion of two-step TB test. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 1, 2022
Visit Reason
Investigation of complaints #108717-C, #107912-C, #107770-C, and incident #106706-I.
Findings
No deficiencies were cited during the investigation of the complaints and incident.
Complaint Details
Investigation of Complaint #108717-C, Complaint #107912-C, Complaint #107770-C, and Incident #106706-I resulted in no deficiencies cited.
Inspection Report
Deficiencies: 0
Nov 30, 2021
Visit Reason
The inspection was conducted as an onsite infection control survey and an investigation into Incident #98850-I.
Findings
No deficiencies were cited during the onsite infection control survey or the investigation into Incident #98850-I.
Inspection Report
Complaint Investigation
Deficiencies: 5
Jul 21, 2021
Visit Reason
The inspection was conducted to investigate Incident #97924-I and to determine compliance with licensing rules for a Residential Care Facility, including an onsite infection control survey.
Findings
Multiple deficiencies were found including failure to complete tuberculosis screenings for residents, lack of authorization for staff to administer insulin, failure to ensure diet orders were obtained quarterly for residents, failure to modify service plans as residents' needs changed, and failure to complete baseline TB screening procedures for residents.
Complaint Details
The visit was triggered by Incident #97924-I. The Executive Director confirmed findings related to tuberculosis screening, insulin administration authorization, diet orders, service plan modifications, and baseline TB screening. Resident #2 was involved in multiple incidents of self-harm and mental health crises documented during the investigation.
Deficiencies (5)
| Description |
|---|
| Facility failed to complete tuberculosis screenings as required by Iowa Administrative Code 481 - Chapter 59 for 1 or 2 residents admitted since March 2021. |
| Facility was unable to provide names of staff authorized to administer insulin to residents. |
| Facility failed to ensure diet orders were obtained on a quarterly basis for 2 of 3 residents reviewed. |
| Facility failed to ensure service plans were modified as needs changed for 1 of 3 residents reviewed. |
| Facility failed to complete baseline TB screening for 1 of 2 residents admitted during the past five months. |
Report Facts
Incident number: 97924
Residents reviewed for diet orders: 3
Residents with missing diet orders: 2
Residents reviewed for service plan modifications: 3
Residents with unmet service plan modifications: 1
Residents admitted since March 2021: 2
Residents admitted in past five months: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Confirmed findings related to tuberculosis screening, insulin administration, diet orders, service plan modifications, and baseline TB screening; reported on Resident #2's condition and incidents |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 30, 2020
Visit Reason
Investigation of Mandatory Report 89413-M and Complaint 89371-A.
Findings
No deficiencies were cited during the investigations of Mandatory Report 89413-M and Complaint 89371-A.
Complaint Details
Investigation of Mandatory Report 89413-M and Complaint 89371-A found no deficiencies.
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