Inspection Reports for Country Manor Memory Care

The inspection was conducted as an annual recertification survey to determine compliance with certification for a Dedicated Dementia-Specific Assisted Living Program, including investigation of complaints #125899-C and #126002-C.

The facility was found to have multiple regulatory insufficiencies related to incident reporting, evaluation of tenants, service plans, nurse reviews, and life safety emergency policies. Deficiencies included failure to complete detailed incident reports, failure to include witness statements, failure to complete evaluations prior to occupancy, failure to update service plans timely, failure to conduct nurse reviews every 90 days, and failure to have operating door alarms connected to each exit door.

The inspection included investigation of complaints #125899-C and #126002-C. The complaints involved aggressive behavior by Tenant #1, including hitting staff and other tenants, and failure of staff to complete detailed incident reports. The tenant was hospitalized after an altercation. The complaint was substantiated as evidenced by multiple findings related to incident reporting and tenant evaluations.

The inspection was conducted as an investigation into Complaint #114635-C regarding regulatory insufficiencies at Country Manor Memory Care.

The investigation found deficiencies related to medication administration, evaluation of tenants, and service plans. Specific issues included failure to administer medications as ordered, incomplete evaluations after significant changes in tenant condition, and failure to update service plans to reflect tenant needs.

The visit was triggered by Complaint #114635-C. The complaint involved medication administration and tenant care issues. The hospice nurse provided wound care orders that were not implemented or discontinued as required. The Executive Director confirmed not receiving wound orders from the hospice nurse. The cardiologist recommended amputation of a tenant's toe due to wound complications.

The inspection was conducted as a complaint investigation into incidents #111401-1 and complaints #11298-C, #114550-C, and #114551-C regarding care and medication administration at the assisted living program.

The program failed to provide appropriate care to 1 of 5 discharged tenants, specifically Tenant C5, who was diagnosed with Alzheimer's and had medication and documentation deficiencies. The program also failed to administer medication properly to Tenant C5 and did not document health care visits and medication administration as required.

No regulatory insufficiencies were cited during the investigation into Incident #111401-1, but regulatory insufficiencies were cited during the investigations into Complaints #114550-C and #114551-C.

The inspection was conducted as a recertification visit for an Assisted Living Program for People with Dementia and included investigations into multiple complaints and incidents.

The program failed to follow its policies and procedures regarding tenant care, including sexual behavior management, emergency transfers, tenant rights, staffing adequacy, staff training, background checks, and individualized service plans. Several tenants' needs were not properly identified or addressed, and supervision was insufficient.

The report includes investigations into multiple complaints (#109854-C, #110767-C, #107888-C, #107954-C, #109955-C, #110978-C) and an incident (#110283-I). No regulatory insufficiencies were cited during the investigation of Complaint #109854-C, Complaint #110767-C, and Incident #110283-I. Deficiencies were cited during investigations of other complaints.

The inspection was conducted as a complaint investigation involving multiple complaints and incidents related to the assisted living program for people with dementia at Country Manor Memory Care.

No regulatory insufficiencies were found for some complaints, but deficiencies were cited related to failure to follow established program policies and procedures for two tenants, and failure to follow narcotic protocols for one tenant, including missing narcotics and inconsistent narcotic counts.

The investigation involved complaints #100368-C, #100369-C, #100403-C, #102661-C, #106548-C and incidents #103873-I, #102385-I, #102453-I. No regulatory insufficiencies were cited for complaints #100368-C, #100369-C, #100403-C, #102661-C. Deficiencies were cited during investigation of complaint #106548-C and incidents #102385-I and #102453-I.

The inspection was conducted as an investigation into multiple incidents and complaints, specifically Incident #97334-I, Incident #98432-I, Complaint #97302-C, and Complaint #97536-C.

No regulatory insufficiencies were cited during the investigation of the incidents and complaints.

Investigation into Incident #97334-I, Incident #98432-I, Complaint #97302-C, and Complaint #97536-C found no regulatory insufficiencies.

The investigation of Incident #96229-I and Complaints #96943-C and #96955-C was completed to assess regulatory compliance related to tenant interactions and medication administration.

The program failed to follow policies regarding sexuality in dementia care, including inadequate communication with legal representatives about tenant intimacy. Medication administration errors occurred, including an extra dose of Melatonin given to a tenant and discrepancies in medication counts. Evaluations and service plans were not completed or updated timely in response to significant changes in tenant behavior.

The visit was complaint-related involving Incident #96229-I and Complaints #96943-C and #96955-C. The complaints involved inappropriate sexual behavior between tenants with dementia and medication administration errors. The sexual relationship between tenants was not fully disclosed to legal representatives, and medication errors included extra doses and missing medications.

The investigation of Complaints #93240-C, #93988-C and #94640-C was completed. An onsite infection control survey and the recertification visit conducted to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program was also completed from 12/1/20 to 3/15/21.

Multiple regulatory insufficiencies were identified including failure to follow established policies and procedures related to infection control, incident reporting, and resident care. Specific findings included improper nebulizer use with a COVID-19 positive tenant, failure to include witness statements in incident reports, inadequate care leading to severe injury and hospitalization of a tenant, insufficient staffing to prevent elopement, incomplete nurse delegations, incomplete background checks, failure to document nurses' notes by exception, incomplete service plans, failure to complete nurse reviews for COVID-19 positive tenants, failure to note physician orders with time, date and signature, failure to complete required visual checks, and structural issues including a damaged fence and a malfunctioning exit door.

The visit was complaint-related involving Complaints #93240-C, #93988-C and #94640-C.

The inspection visit was conducted to investigate Complaint #91827-C related to tenant rights and staffing at Country Manor Memory Care.

The investigation found regulatory insufficiencies in tenant rights and staffing. Specifically, the program failed to ensure adequate care and treatment for a tenant with diabetes, including medication administration errors and insufficient staff training on insulin administration and blood sugar monitoring.

Complaint #91827-C was investigated. The complaint was substantiated based on findings of medication errors and inadequate staff training related to diabetes care for Tenant #1.

The inspection was conducted as a complaint investigation into Incident #86493-I involving tenant safety and care concerns at Country Manor Assisted Living Program for People with Dementia.

The program failed to consistently provide adequate services to meet tenant needs, resulting in an elopement incident where Tenant #1 was found outside the facility with injuries. The service plan did not include the tenant's exit-seeking behavior, and the courtyard door was found propped open multiple times, allowing unauthorized exit.

Complaint visit conducted 11/18/19 - 11/19/19 regarding Incident #86493-I involving Tenant #1 eloping from the facility and sustaining injuries. The complaint was substantiated based on interviews, record reviews, and observations.

The inspection was conducted as a complaint investigation related to Complaints #83177-C, #83178-C, #83183-C, #83192-C, and #83926-C at Country Manor, an assisted living program for people with dementia.

The investigation found multiple regulatory insufficiencies including failure to follow medication policies, inadequate incident reporting, failure to provide adequate and appropriate services to tenants, incomplete nurse delegation training, failure to update service plans, and failure to maintain the building in a clean and safe condition.

Complaint investigation related to Complaints #83177-C, #83178-C, #83183-C, #83192-C, and #83926-C.

Investigation of Incident #82234-I at the Assisted Living Program for People with Dementia.

No regulatory insufficiencies were cited during the investigation.

Investigation of Incident #82234-I; no deficiencies found.

The revisit of the recertification visit, complaints #75208-C, #75209-C, #75823-C and Incident #75340-I resulted in regulatory insufficiencies. During the course of the revisit, the investigation of Incident #77948-I was also conducted.

The program failed to provide adequate care, treatment, and services to a tenant who fell and sustained a fracture. The investigation revealed multiple failures in incident reporting, communication, and implementation of the plan of correction. The program also failed to develop and follow individualized service plans for tenants.

Complaint investigation included complaints #75208-C, #75209-C, #75823-C and Incident #75340-I, and investigation #77948-I. The investigation found regulatory insufficiencies related to tenant care and service plans.

The recertification visit was conducted to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program. The investigation of Complaints #75208-C, #75209-C, 75823-C, and Incident #75340-I resulted in regulatory insufficiencies.

The program failed to ensure completion of incident reports for all incidents, failed to ensure tenants received adequate and appropriate care including appropriate supports and supervision, failed to ensure appropriate medical follow-up after alleged sexual assault, failed to ensure staff were sufficiently trained and competent, and failed to provide required training on dependent adult abuse and dementia-specific education. Multiple incidents involving tenant interactions and staff responses were documented.

The visit was complaint-related involving multiple complaints and an incident (#75208-C, #75209-C, 75823-C, and #75340-I). The investigation found regulatory insufficiencies related to incident reporting, tenant rights, staffing, training, and care provision.

The visit included investigation of Incident #70760-I and Incident #70763-I, and a revisit of Incident #70048-I and Complaint #70170-C to verify correction of previously cited regulatory insufficiencies.

No regulatory insufficiencies were cited from the investigations of Incident #70760-I and Incident #70763-I. Previously cited regulatory insufficiencies from Incident #70048-I and Complaint #70170-C were corrected.

The inspection was a second revisit of investigation #64658-I and investigations of incidents #68237-I, 70048-I, and complaint #70171-C, focusing on regulatory insufficiencies related to incident reports, tenant rights, criteria for admission/retention, service plans, nurse review, and failure to implement previous plans of correction.

The investigation found multiple regulatory insufficiencies including failure to complete incident reports, inadequate care and treatment, failure to comply with admission and retention criteria, incomplete service plans, and failure to conduct nurse reviews as required. Several tenants exhibited severe cognitive decline and incidents of sexual and physical aggression were documented. A fall resulting in a fractured femur was not properly managed in a timely manner.

The visit was complaint-related involving allegations of sexual and physical abuse by Tenant #7 and inadequate care following a fall of Tenant #5. The complaint was substantiated with regulatory insufficiencies cited.

A revisit of the investigation of Incident #64658-I was completed to investigate regulatory insufficiencies related to incident reports and service plans at Country Manor Assisted Living Program.

The program failed to ensure incident reports were completed for all incidents and did not include statements from witnesses. The program also failed to develop individualized service plans reflecting tenants' identified needs and preferences, particularly for tenants #2 and #3. The plan of correction was not implemented as of the effective date.

Complaint/Incident Intake #64658-I investigated allegations related to incident reports and service plans. The complaint was substantiated as regulatory insufficiencies were identified.

The inspection was conducted as a complaint/incident investigation related to regulatory insufficiency concerning service plans at Country Manor, an assisted living facility with a dementia-specific program.

The investigation found that the program failed to develop individualized service plans reflecting identified tenant needs, specifically interventions to address elopement for two tenants. The facility had a total census of 34 tenants at the time of the visit, with 31 having cognitive disorders. The report detailed incidents of elopement and inadequate service plan interventions for two tenants with dementia.

The complaint/incident investigation was triggered by Incident #64658-I. The investigation substantiated regulatory insufficiency related to service plans for tenants with dementia and elopement risk.

The inspection was conducted as a Final Recertification & Complaint/Incident Investigation following a complaint intake #60565-I, focusing on tenant rights, staffing, and record checks at Country Manor, Davenport, IA.

The report identified regulatory insufficiencies related to tenant rights, staffing, and record checks. Tenant #1 eloped from a locked dementia unit and sustained injuries, and the program lacked sufficient trained staff and complete record checks for employment.

Complaint investigation related to Tenant #1 eloping from a locked dementia unit on 6-8-16, resulting in injuries. The complaint was substantiated with findings of inadequate care, staffing, and record checks.

The inspection was conducted as a recertification and investigation of Incident #60565-I involving tenant elopement and related regulatory insufficiencies at Country Manor Assisted Living Program.

The inspection found multiple regulatory deficiencies including failure to provide adequate care and treatment to a tenant who eloped, insufficient staffing to meet tenant needs, and incomplete criminal background record checks for staff.

The complaint investigation was triggered by an incident where Tenant #1, a 79-year-old with severe cognitive decline, eloped from the facility on 6-8-16 and was found injured outside. The investigation included interviews with staff and review of incident reports and door alarm functionality.

The inspection was conducted following a complaint/incident investigation by the Department of Inspections and Appeals (DIA) on November 16, 2015, related to tenant care and rights at Country Manor, Davenport, Iowa.

No tenants exceeded the level of care and no concerns with Admission/Discharge or Tenant Rights were identified. However, a regulatory insufficiency was found in the area of Nurse Review, specifically that 90 day nurse reviews were not completed as required for some tenants.

The complaint investigation included allegations regarding Admission/Discharge and Tenant Rights, both found not substantiated. The regulatory insufficiency was related to Nurse Review requirements not being met.

The visit was a final recertification monitoring evaluation conducted to assess compliance with Iowa Code and Administrative Code chapters for the assisted living program at Country Manor Memory Care.

No regulatory insufficiencies were found during the evaluation. The facility was observed to be safe, clean, and sanitary, with tenants and family expressing satisfaction with the program and services.

The inspection was conducted as a final complaint/incident investigation of Country Manor Assisted Living Program following a complaint intake #40045-I. The investigation focused on regulatory insufficiencies related to evaluation, criteria for admission and retention, service plans, policies and procedures, staffing, compliance with plan of correction, and structural requirements.

The investigation found multiple regulatory insufficiencies including failure to comply with policies and procedures, staffing issues, inadequate service plans, and structural concerns such as unsecured courtyard doors. The program was assessed a $1,000 civil penalty and the plan of correction submitted was reviewed but requests for reconsideration on several issues were denied.

Complaint/Incident Intake #40045-I involved multiple elopements by Tenant #1 and other concerns related to tenant safety, wandering, and program compliance. The complaint was substantiated with findings of regulatory insufficiencies.

The inspection was conducted as a complaint/incident investigation regarding allegations that the assisted living program did not have a policy on pets and that a pet living at the program was not cared for by the tenant or staff.

The investigation found that the program had a pet policy and occupancy agreement with pet deposit requirements, and that Tenant #1 had cared for the dog appropriately. Multiple staff and family statements confirmed proper care and supervision. Several incidents involving tenant falls were reviewed, with no regulatory insufficiencies noted related to these incidents.

The complaint alleged the program lacked a pet policy and that a pet was not cared for by the tenant or staff. The investigation found the program had a pet policy, and the tenant cared for the dog properly. No regulatory insufficiencies were substantiated.

The visit was conducted as a Final Recertification Monitoring Evaluation to review the facility's Plan of Correction and Request for Reconsideration related to regulatory insufficiencies in the Assisted Living Program.

The program failed to follow policies and procedures related to alarmed exit doors, medication administration, food service menu planning, life safety alarms, and transportation safety equipment. The Department of Inspections and Appeals accepted the Plan of Correction and Request for Reconsideration.

A complaint investigation on-site visit was conducted at Country Manor on March 8, 2011, to investigate allegations related to nursing follow-up and care.

The investigation found regulatory insufficiencies related to nurse review and delegation, including failure to conduct appropriate nurse follow-up after an incident and lack of nurse delegation training for medication administration. Several tenant incidents involving falls and injuries were documented, with some medication administration inconsistencies noted.

Complaint Intake #32900-C involved allegations of inappropriate nurse follow-up related to an incident where a tenant fell and sustained injuries. The complaint was investigated with multiple staff interviews and tenant file reviews. The complaint was substantiated with findings of regulatory insufficiencies.

An on-site visit was conducted to investigate an incident involving a tenant eloping from the assisted living program. The investigation was triggered by an incident report and complaint regarding the tenant's elopement and door alarm failures.

The investigation found that the tenant eloped but was safely returned without injury. Door alarms did not sound during the elopement, and staff responded by implementing new policies including door code changes and increased monitoring. No regulatory insufficiencies were identified in this investigation.

The investigation was complaint-related, focusing on an incident where a tenant eloped and door alarms failed to sound. The complaint was substantiated in that the alarms did not sound, but no injuries occurred and corrective actions were taken.

A complaint investigation on-site visit was conducted at Country House Residences on January 13, 2009 and February 18, 2009 to investigate regulatory insufficiencies related to medications, staffing, and other tenant safety concerns.

The program had regulatory insufficiencies in medications administration, staffing, and other areas including failure to consistently provide trained staff to meet tenant needs and missing medications. The program was under a Conditional Certificate with sanctions and a $2,500 civil penalty was assessed.

The complaint investigation was substantiated with findings of missing medications (30 missing Risperdal pills), insufficient trained staff, and failure to fully implement the Plan of Correction from a prior complaint. The tenant was found with dried food on clothing and wearing a soiled adult incontinence product. Sexual inappropriate behavior by a tenant's spouse was reported but not fully addressed by staff.

A complaint investigation on-site visit was conducted at Country House Assisted Living on December 31, 2008, to investigate regulatory insufficiencies related to medications, life safety, structural requirements, and other areas.

The investigation found multiple regulatory insufficiencies including medication administration errors, failure to provide an operating alarm system on exit doors in the dementia-specific program, unsecured kitchen cabinets and knives, and unmaintained building and grounds. The program did not implement the previously submitted plan of correction for medications. A civil penalty of $4,000 was assessed and the program's plan of correction was accepted.

The complaint investigation was substantiated with findings of regulatory insufficiencies in medications, life safety, structural requirements, and other areas. A tenant was reported to have eloped but was found unharmed. The program was fined $4,000 and accepted the plan of correction.

The inspection was conducted as a Final Complaint Investigation, Complaint Revisit, and Recertification Monitoring Evaluation at Country House Residences, triggered by complaint intake #18835 and revisit #17623R1.

The report found substantiated regulatory insufficiencies in areas including Evaluation of Tenant, Service Plan, Nurse Review, Medications, Staffing, Record Checks, and Food Service. The program's Plan of Correction was accepted, and a civil penalty of $1,500 was assessed.

The complaint investigation was substantiated, noting regulatory insufficiencies related to tenant evaluation, service plans, nurse review, medications, staffing, and other areas. The program was required to pay a civil penalty and submit a Plan of Correction.

An on-site visit was conducted at Country House on June 25, 2008, to investigate a self-reported incident alleging abuse involving multiple tenants and staff.

The investigation found multiple regulatory insufficiencies including inconsistent evaluation of tenants' functional and cognitive status, inadequate service plans, incomplete nurse reviews, insufficient staffing and training, and failure to complete required employee background checks. Staff were observed and reported to have engaged in inappropriate and potentially abusive behaviors toward tenants.

The complaint involved allegations that Staff #1 called tenants names, threatened them, forcefully yanked items away, and physically manhandled tenants. Staff #2 witnessed multiple incidents and reported them. Staff #1 was suspended pending investigation. No evidence of abuse was found, but regulatory insufficiencies were identified.

A complaint investigation was conducted at Country House, Davenport, IA, triggered by allegations of bruising on a tenant and concerns about staff response and documentation.

The investigation found regulatory insufficiencies related to nurse review and staffing, including failure to assess and document tenant health status changes and insufficient trained staff availability. The alleged abuse incident was not substantiated by the Department of Human Services.

The complaint alleged Tenant #1 had bruising on his/her arms from an unidentified staff member and a lapse of 34 hours between the incident and nurse assessment. The DHS investigation found the alleged incident was not founded.

A complaint investigation on-site visit was conducted at Country House on March 25, 2008, in response to complaint intake #16615 regarding various allegations including medication management, tenant falls, and safety concerns.

The investigation found multiple regulatory insufficiencies related to tenant evaluations, service plans, medication administration, nursing services, staffing, and safety protocols. Some allegations were substantiated while others were not, and the program was required to submit a Plan of Correction.

Complaint investigation involved allegations of unlocked narcotics, missing medications, failure to administer PRN medications, delayed reporting of tenant falls and injuries, insufficient staff response to falls, tenants attempting to elope, staff access to medications without certification, and inadequate sanitation practices. Some allegations were substantiated with observations and documentation; others were not.

A complaint investigation on-site visit was conducted at Country House to investigate allegations that tenants' needs were not being met due to various responsibilities of the direct care staff.

The investigation found that staffing levels and practices were appropriate, with direct care staff adequately meeting tenant needs. Interviews with staff and family members indicated satisfaction with care and activities provided. No regulatory insufficiencies were noted.

The complaint was substantiated relating to staffing and occupancy and transfer criteria. The specific allegation was that tenants' needs were not being met due to various responsibilities of the direct care staff. The investigation found no regulatory insufficiencies in staffing.

An on-site monitoring evaluation was conducted to assess compliance with assisted living program regulations as part of the initial certification monitoring evaluation.

The on-site monitor found no regulatory insufficiencies during the evaluation. Tenant and family satisfaction was generally positive, with tenants feeling safe, satisfied with staff, activities, and food, and the facility being well maintained.