Inspection Reports for Edencrest at Green Meadows
6750 Corporate Dr, Johnston, IA 50131, United States, IA, 50131
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 6, 2025, found no deficiencies during the complaint investigation. Earlier inspections generally showed compliance, with most complaint investigations resulting in no regulatory insufficiencies. Deficiencies identified in prior years mainly involved medication administration, documentation, and securing wheelchairs during transport, with one incident in 2022 resulting in injury to a tenant. Complaint investigations were mostly unsubstantiated except for medication administration issues found in 2017 and documentation concerns noted at initial certification. The facility’s record shows improvement over time, with no deficiencies cited in the last several inspections.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
1.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
68% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
51 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 0
Date: Mar 6, 2025
Visit Reason
Investigation of Complaints #123396-C and #123400-C at an assisted living program for people with dementia.
Complaint Details
Investigation of Complaints #123396-C and #123400-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints.
Report Facts
Number of tenants without cognitive disorder: 34
Number of tenants with cognitive disorder: 17
Total Census: 51
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 0
Date: Jul 11, 2024
Visit Reason
The inspection was conducted to investigate complaints numbered 119874-C, 119895-C, and 119934-C, as well as Incident 119887-I at the assisted living facility.
Complaint Details
Investigation of Incident 119887-I and Complaints 119874-C, 119895-C, and 119934-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: 33
Number of tenants with cognitive impairment: 23
Total census: 56
Inspection Report
Renewal
Census: 57
Deficiencies: 0
Date: Jan 25, 2024
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification visit or during the investigation of Incident #114836-I.
Report Facts
Number of tenants without cognitive impairment: 38
Number of tenants with cognitive impairment: 19
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 1
Date: Dec 1, 2022
Visit Reason
The inspection was conducted as a result of investigation of Incident #109237-I and Complaint #109191-C related to transportation safety concerns at the assisted living program.
Complaint Details
The investigation pertained to Incident #109237-I and Complaint #109191-C. No regulatory insufficiencies were cited for Complaints #107724-C and #106357-C. The tenant suffered a fractured neck and collarbone and ongoing pain after the incident. The tenant's daughter confirmed injuries and loss of strength due to being bedridden with Parkinson's disease.
Findings
The program failed to properly secure a wheelchair during transport of a tenant, resulting in the tenant's transport chair tipping over and causing injury. The Director was observed attaching the wheelchair hooks incorrectly, and the tenant suffered a fractured neck and collarbone.
Deficiencies (1)
Failed to properly secure a wheelchair during transport of a tenant, resulting in injury.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 38
Number of tenants with cognitive disorder in General Population Program: 1
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 22
Total census of Assisted Living Program for People with Dementia: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alex McGregor | Community Director | Signed the plan of correction and mentioned as Director involved in the incident |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Date: Dec 19, 2019
Visit Reason
Investigation of Incident #87245-C at an Assisted Living Program for People with Dementia.
Complaint Details
Investigation of Incident #87245-C; no deficiencies found.
Findings
No regulatory insufficiencies were cited during the investigation.
Report Facts
Number of tenants without cognitive disorder in General Population: 41
Number of tenants with cognitive disorder in General Population: 7
Number of tenants without cognitive disorder in Memory Care Unit: 6
Number of tenants with cognitive disorder in Memory Care Unit: 16
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 0
Date: Mar 14, 2019
Visit Reason
Investigation of Complaint #81450-C at an Assisted Living Program for People with Dementia.
Complaint Details
Complaint #81450-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Census: 63
Number of tenants without cognitive disorder: 35
Number of tenants with cognitive disorder: 6
Number of tenants without cognitive disorder: 8
Number of tenants with cognitive disorder: 13
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 0
Date: Oct 31, 2018
Visit Reason
Investigation of Complaint #79167-C regarding the Assisted Living Program for People with Dementia.
Complaint Details
Complaint #79167-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder (General Population): 32
Number of tenants with cognitive disorder (General Population): 6
Number of tenants without cognitive disorder (Memory Care Unit): 8
Number of tenants with cognitive disorder (Memory Care Unit): 10
Total Census of Assisted Living Program for People with Dementia: 56
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 0
Date: Oct 8, 2018
Visit Reason
Investigation of complaint #78152-C at the assisted living facility Edencrest at Green Meadows.
Complaint Details
Complaint #78152-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Report Facts
Number of tenants without cognitive disorder in General Population program: 31
Number of tenants with cognitive disorder in General Population program: 4
Total population of General Population program: 36
Number of tenants without cognitive disorder in Dementia-Specific program: 8
Number of tenants with cognitive disorder in Dementia-Specific program: 9
Total population of Dementia-Specific program: 17
Total census of Assisted Living Program: 53
Inspection Report
Renewal
Census: 53
Deficiencies: 0
Date: Jul 26, 2018
Visit Reason
Recertification visit conducted to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the recertification visit for the Assisted Living Program for People with Dementia.
Report Facts
Number of tenants without cognitive disorder in General Population: 32
Number of tenants with cognitive disorder in General Population: 5
Number of tenants without cognitive disorder in Memory Care Unit: 7
Number of tenants with cognitive disorder in Memory Care Unit: 9
Total Census: 53
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Date: Jan 11, 2018
Visit Reason
The inspection was conducted as part of investigations of Complaint #72567-C and Complaint #73015-C at the assisted living program for people with dementia.
Complaint Details
Investigations of Complaint #72567-C and Complaint #73015-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigations of the complaints.
Report Facts
Census: 55
Number of tenants without cognitive disorder: 40
Number of tenants with cognitive disorder: 15
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Date: Nov 7, 2017
Visit Reason
Investigation of complaint #71326-C at the assisted living program.
Complaint Details
Complaint #71326-C was investigated and found to have no regulatory insufficiency.
Findings
No regulatory insufficiency was cited during the investigation of the complaint.
Report Facts
Number of tenants without cognitive disorder: 42
Number of tenants with cognitive disorder: 13
Total Population of Program at time of on-site: 55
TOTAL census of Assisted Living Program: 55
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 5
Date: Sep 26, 2017
Visit Reason
Investigation of complaints #69393-C and #70885-C was completed to assess regulatory compliance at Edencrest at Green Meadows assisted living program.
Complaint Details
Investigation of Complaints #69393-C and #70885-C was completed and regulatory insufficiencies were identified.
Findings
Regulatory insufficiencies were identified related to program policies and procedures, medication administration, staffing, and tenant documentation. Multiple deficiencies were noted in medication counts, administration records, nurse delegation, service plans, and documentation of tenant care.
Deficiencies (5)
Program failed to follow policies and procedures related to medication administration including narcotic medication for 3 of 7 tenants reviewed.
Failure to ensure medication administration records and narcotic counts were consistently reconciled and documented.
Program failed to ensure registered nurse documented review to ensure staff were sufficiently trained within 60 days of employment for 2 of 6 staff and 2 of 3 staff reviewed hired prior to nurse delegation.
Program failed to administer medications as ordered for 4 of 7 tenants reviewed.
Program failed to maintain accurate tenant documentation including progress notes, medication administration records, and service plans for multiple tenants.
Report Facts
Census: 55
Tenants reviewed: 7
Staff reviewed: 6
Staff reviewed: 3
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Date: Mar 2, 2017
Visit Reason
The inspection was conducted as a result of Complaint #64601-C to investigate regulatory insufficiencies related to medication administration at Edencrest at Green Meadows.
Complaint Details
Complaint #64601-C was investigated and substantiated based on findings that medication administration policies were not followed, resulting in missed medication doses for Tenant #2.
Findings
The program failed to administer tenant medications as ordered, affecting 1 of 2 tenants reviewed. Staff did not give warfarin as ordered due to medication unavailability and failed to notify the nurse, resulting in missed doses over several days.
Deficiencies (1)
Program failed to administer tenant medications as ordered, including missed doses of warfarin due to medication unavailability and lack of notification to nursing staff.
Report Facts
Number of tenants without cognitive disorder: 40
Number of tenants with cognitive disorder: 9
Total census of Assisted Living Program: 49
Tenants affected by medication administration deficiency: 1
Inspection Report
Original Licensing
Census: 39
Deficiencies: 3
Date: Aug 11, 2016
Visit Reason
The inspection was conducted as an initial certification visit to determine compliance with certification for an Assisted Living Program for People with Dementia (ALP/D).
Findings
The inspection identified regulatory insufficiencies related to service plans, nurse reviews, and documentation of nursing facility care preferences for tenants. Specific deficiencies included unsigned service plans, lack of nursing reviews following significant health changes, and failure to document nursing facility care preferences.
Deficiencies (3)
Service plans were not signed and dated when updated with change for three tenants.
The program failed to document tenants' identified nursing facility care preferences.
Nurse reviews to assess and document health status were not completed following significant changes in condition for three tenants.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 30
Number of tenants with cognitive disorder in General Population Program: 1
Total Population of General Population Program: 31
Number of tenants without cognitive disorder in Dementia-Specific Program: 2
Number of tenants with cognitive disorder in Dementia-Specific Program: 6
Total Population of Dementia-Specific Program: 8
Total census of Assisted Living Program: 39
Number of tenant clinical records reviewed: 4
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