Inspection Reports for Edencrest at Pleasant Hill
6151 Martha L. Miller Dr, Pleasant Hill, IA 50327, USA, IA, 50327
Back to Facility ProfileDeficiencies (last 1 years)
Deficiencies (over 1 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
82% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
30 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 2
Sep 10, 2025
Visit Reason
The inspection was conducted as an investigation of incidents #129937-I, #130182-I, and complaints #130127-C, #130205-C at Edencrest at Pleasant Hill.
Findings
The program failed to complete an evaluation due to significant change and failed to update the service plan for Tenant #5 following the start of hospice services. Staff were unaware of the tenant's hospice status, and evaluations and service plans did not reflect this significant change.
Complaint Details
The investigation was triggered by complaints #130127-C and #130205-C and incidents #129937-I and #130182-I. The findings were substantiated by record review and interviews confirming failure to evaluate and update service plans after significant changes for Tenant #5.
Deficiencies (2)
| Description |
|---|
| Failed to complete an evaluation due to significant change for Tenant #5, specifically not addressing the start of hospice services. |
| Failed to update the service plan for Tenant #5 following a significant change, specifically the start of hospice services. |
Report Facts
Number of tenants without cognitive impairment: 17
Number of tenants with cognitive impairment: 13
Total census: 30
Tenants reviewed: 5
Tenant with deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Regional Clinical Services Coordinator | Confirmed via email and phone the failure to complete evaluation and update service plan for Tenant #5. | |
| Executive Director | Confirmed findings regarding Tenant #5's evaluation and service plan deficiencies. | |
| Assistant Director of Wellness | Confirmed findings regarding Tenant #5's evaluation and service plan deficiencies. |
Inspection Report
Original Licensing
Census: 23
Deficiencies: 6
Jun 18, 2025
Visit Reason
The inspection was conducted as an initial certification visit to determine compliance with certification rules for an Assisted Living Program for People with Dementia.
Findings
The program was found to have multiple regulatory insufficiencies including failure to follow its own medication policy resulting in a medication error, failure to request required criminal background evaluations for staff, failure to ensure validity of background checks, failure to complete evaluations and update service plans following significant tenant changes, and failure to ensure proper signatures on preliminary service plans.
Deficiencies (6)
| Description |
|---|
| Failed to follow its own written medication policy for 1 of 4 tenants reviewed, resulting in a medication administration error where Tenant 1 received a 15 mg morphine tablet instead of 5 mg morphine solution and no Medication Error Report was completed. |
| Failed to request an evaluation from the Department of Health and Human Services prior to employment for 1 of 3 staff reviewed with a criminal history (Staff A). |
| Failed to ensure the validity of background checks for 1 of 7 employee files reviewed (Staff C), as background check results were older than 30 days at time of hire. |
| Failed to complete an evaluation due to significant change for 1 of 4 tenants reviewed (Tenant 1) after hospice services began. |
| Failed to update the service plan following a significant change for 1 of 4 tenants reviewed (Tenant 1) to reflect hospice services. |
| Failed to ensure a preliminary service plan was signed by all parties for 1 of 4 tenants reviewed (Tenant 2); program staff who developed the plan did not sign it. |
Report Facts
Number of tenants without cognitive impairment: 11
Number of tenants with cognitive impairment: 12
Total census: 23
Tenants reviewed: 4
Staff reviewed with criminal history: 3
Employee files reviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Staff with criminal history for whom evaluation from Department of Health and Human Services was not requested prior to employment. | |
| Staff C | Employee whose background check was not valid within 30 days of hire date. | |
| Regional Director of Clinical Services | Interviewed and confirmed findings related to medication error, background checks, and evaluation deficiencies. | |
| Executive Director | Interviewed and confirmed findings related to medication error, background checks, and evaluation deficiencies. |
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