Inspection Reports for Edgewater, a WesleyLife Community for Healthy Living
IA, 50266
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 12, 2025
Visit Reason
A complaint investigation was conducted for facility reported incidents #Incident 2657311 from November 10, 2025 to November 12, 2025.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Investigation related to incident #2657311; facility found in substantial compliance.
Report Facts
Incident number: 2657311
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 1
Oct 16, 2025
Visit Reason
The inspection was conducted as an investigation of facility reported incidents #2591279-1 on October 16, 2025.
Findings
The facility failed to provide adequate nursing supervision to prevent a resident from exiting the facility into an unsafe patio area without staff knowledge. The resident had moderate cognitive impairment and wandered 1 to 3 days in a 7-day period. Staff failed to check and secure patio doors properly, leading to an elopement risk.
Complaint Details
Investigation of facility reported incidents #2591279-1. The complaint was substantiated with findings of inadequate supervision and door security leading to resident elopement risk.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure adequate supervision and assistance devices to prevent accidents, specifically a resident exiting into an unsafe area. | D |
Report Facts
Resident census: 39
Brief Interview for Mental Status (BIMS) score: 12
Number of residents reviewed: 4
Days resident wandered: 3
Date of progress note: 81425
Date of facility self-report: 81525
Date of policy revision: 72024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide (CNA) | Demonstrated proper functioning of long-term care door alarms on 10/16/25 at 10:45 AM. |
| Staff B | Licensed Practical Nurse (LPN) | Reported resident was fully clothed outside facility and redirected him back to room on 10/16/25 at 11:29 AM. |
| Staff C | Licensed Practical Nurse (LPN) | Stated staff must verify patio doors are locked at beginning and middle of each shift on 10/16/25 at 12:53 PM. |
| Director of Nursing | Director of Nursing (DON) | Stated facility door codes were changed and staff should meet resident's basic needs on 10/16/25 at 1:48 PM. |
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 19, 2025
Visit Reason
An annual recertification survey was conducted from June 16, 2025 to June 19, 2025.
Findings
The facility was found to be in substantial compliance at the time of the survey.
Inspection Report
Plan of Correction
Deficiencies: 0
May 1, 2025
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility will be certified in compliance effective May 1, 2025, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Apr 16, 2025
Visit Reason
The inspection was conducted as a result of complaint #127837-C, which was substantiated following an investigation from April 10, 2025 to April 16, 2025.
Findings
The facility failed to provide timely assessment and interventions for one resident who experienced a change in condition, including delayed response to respiratory distress and inadequate monitoring of oxygen saturation levels. The complaint was substantiated based on clinical record review, staff interviews, and policy review.
Complaint Details
Complaint #127837-C was substantiated based on investigation findings.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide timely assessment and interventions for a resident with a change in condition. | SS=D |
Report Facts
Resident census: 40
Oxygen saturation levels: 75
Oxygen saturation levels: 83
Oxygen saturation levels: 77
Temperature: 102
Blood pressure: 131
Blood pressure: 93
Respiratory rate: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brenda O'May | Director of Nursing | Named in relation to findings and plan of correction |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 7, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on November 7, 2024, related to the facility's compliance status.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction, resulting in certification of compliance effective November 7, 2024.
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 3
Oct 17, 2024
Visit Reason
The inspection was conducted as a result of investigation of Complaint #123903-C from October 16 to October 17, 2024. The complaint was substantiated.
Findings
The facility failed to follow physician orders for dressing changes for one resident, failed to secure prescribed medications from unauthorized access, and failed to protect resident information from unauthorized access. The facility also lacked a policy specific to following physician orders and had documentation and medication storage deficiencies.
Complaint Details
Complaint #123903-C was substantiated following investigation conducted October 16-17, 2024.
Severity Breakdown
SS=D: 1
SS=E: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to follow physician orders for dressing changes for Resident #3. | SS=D |
| Failed to secure prescribed medications from unauthorized access; medication room door was propped open and medications left unsecured. | SS=E |
| Failed to protect resident information from unauthorized access; resident information was left visible on a table in an open area with no staff present. | SS=E |
Report Facts
Census: 40
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse (RN) | Interviewed regarding dressing change for Resident #3 |
| Staff C | Registered Nurse (RN) | Interviewed regarding dressing change for Resident #3 |
| Staff D | Registered Nurse (RN) | Interviewed regarding dressing change for Resident #3 |
| Staff A | Licensed Practical Nurse (LPN) | Interviewed regarding medication storage and resident information confidentiality |
| Director of Nursing | Director of Nursing (DON) | Provided statements on medication room door policy, signing off orders, and confidentiality practices |
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 8, 2024
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and demonstrate compliance for certification.
Findings
The facility submitted a credible allegation of compliance and plan of correction, resulting in certification of compliance effective July 24, 2024. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 2
Jul 15, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey from July 13, 2024 to July 15, 2024.
Findings
The facility failed to serve appropriate food portions to 5 residents receiving mashed potatoes during lunch and failed to maintain sanitary practices in food storage and service areas, including improper labeling and uncovered food items. Staff were also observed not following proper hand hygiene and food safety protocols.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to serve appropriate portions for 5 residents who received mashed potatoes for lunch. | SS=E |
| Facility failed to maintain sanitary practices by improperly storing and serving food and not wearing beard coverings in the food service area. | SS=E |
Report Facts
Residents affected: 5
Census: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Homemaker cook | Observed placing food serving utensils and serving resident plates |
| Staff B | Homemaker cook | Identified use of incorrect serving scoop for mashed potatoes |
| Staff A | Homemaker Cook | Observed improper hand hygiene and food handling during meal service |
| Staff C | Sous Chef | Observed preparing food with uncovered facial hair |
| Staff D | Sous Chef | Observed preparing food with uncovered facial hair |
| Staff E | Homemaker Cook | Observed improper hand hygiene and food handling during meal service |
| Director of Nursing | Director of Nursing | Signed the statement of deficiencies |
| Dietary Manager | Dietary Manager | Provided observations and statements regarding food service and hygiene practices |
| Assistant Director of Food & Beverage | Assistant Director of Food & Beverage | Responsible for auditing and monitoring compliance as part of plan of correction |
Inspection Report
Annual Inspection
Deficiencies: 0
Nov 30, 2023
Visit Reason
The inspection was conducted as an annual recertification survey with an investigation of multiple intakes (#112688-C, #112689-C, #115455-I, #116268-I, #116443-C, and #117079-C) from November 27, 2023 to November 30, 2023.
Findings
Edgewater, A WesleyLife Community Nursing Home was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities based on the annual recertification survey and complaint investigations.
Inspection Report
Abbreviated Survey
Census: 39
Deficiencies: 0
Feb 14, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 2/14/23 to assess compliance with CMS and CDC recommended practices.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 17, 2022
Visit Reason
An onsite revisit survey was conducted for the recertification survey investigation of multiple intakes ending on July 27, 2022.
Findings
All deficiencies identified in the prior investigation have been corrected and the facility is in compliance with all surveyed regulations.
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 6
Jul 27, 2022
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of facility reported incidents and complaints.
Findings
The facility was found deficient in multiple areas including failure to notify the Long Term Care Ombudsman of resident transfers, incomplete comprehensive care plans for residents, inadequate supervision and assistance to prevent falls, incomplete nursing assessments before and after dialysis treatments, unsanitary food preparation and storage conditions, and lack of required personnel attendance at Quality Assurance meetings.
Deficiencies (6)
| Description |
|---|
| Failure to notify the Long Term Care Ombudsman of resident transfers for two of three residents reviewed. |
| Failure to develop and implement comprehensive care plans for two residents, including lack of directives for dialysis care and fall prevention. |
| Failure to provide adequate supervision and assistance to prevent falls and failure to properly investigate fall incidents for one resident. |
| Failure to complete nursing assessments and monitoring before and after outpatient dialysis treatments for one resident. |
| Failure to ensure sanitary environment for food preparation and storage, including uncovered food, dust accumulation, open trash bins, and inconsistent temperature monitoring. |
| Failure to ensure Quality Assurance committee meetings had required personnel attendance including Administrator and Medical Director. |
Report Facts
Residents reviewed: 15
Residents reviewed: 4
Residents reviewed: 2
Temperature log missing days: 6
Residents census: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Social Worker | Reported on resident transfer notification issues |
| Staff B | Registered Nurse | Reported on dialysis assessment documentation process |
| Staff C | Certified Nurse Aide | Provided information on NuStep equipment use and fall incident |
| Staff D | Certified Nurse Aide | Verified fall incident and supervision issues |
| Staff E | Registered Nurse | Documented fall incident and described fall handling process |
| Staff F | Certified Nurse Aide | Reported on fall incident and transfer of resident |
| Staff G | Registered Nurse | Nurse during fall incident, described fall handling and transfer |
| Staff H | Certified Nurse Aide | Involved in fall incident, removed from schedule |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding fall incidents, dialysis assessments, and QA meetings |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided information on QA meetings and fall incident investigations |
| Director of Therapy | Director of Therapy | Reported expectations for therapy session supervision |
| Restaurant Manager | Restaurant Manager | Provided information on kitchen conditions and temperature monitoring |
Inspection Report
Renewal
Census: 37
Deficiencies: 8
Jun 23, 2021
Visit Reason
The Iowa Department of Inspections and Appeals conducted a Medicare Recertification Survey and Investigation of complaints for Edgewater, a WesleyLife Community, resulting in a finding of non-compliance.
Findings
The facility was found not in compliance with multiple Medicare Conditions of Participation, including failure to post survey results accessibly, failure to notify physicians and family representatives of changes or incidents, failure to carry out PASARR assessments, failure to meet professional standards in care plans and medication administration, failure to provide adequate restorative services, failure to prevent accidents, and failure to maintain food safety standards.
Complaint Details
Complaint numbers #92293-C and #94662-C were not substantiated; #96240-C and #96419-C were substantiated.
Deficiencies (8)
| Description |
|---|
| Facility failed to place survey results in an accessible area for residents and families. |
| Facility failed to notify physician and/or resident representative of changes including falls, weight changes, and skin conditions for multiple residents. |
| Facility failed to carry out PASARR requirements for resident #10. |
| Facility failed to meet professional standards for insulin pen priming and timely food consumption for resident #25. |
| Facility failed to carry out restorative programs for multiple residents and lacked documentation of staff assistance. |
| Facility failed to ensure resident environment was free of accident hazards and failed to implement fall interventions. |
| Facility failed to ensure residents were free of significant medication errors related to insulin administration. |
| Facility failed to comply with food safety requirements including staff hairnet use and handwashing. |
Report Facts
Total residents: 37
Survey dates: From 2021-06-14 to 2021-06-23
Correction date: Planned correction date 2021-07-23
Deficiencies cited: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse | Named in medication administration deficiency involving insulin pen priming and dosing for Resident #25 |
| Staff D | Advanced Registered Nurse Practitioner | Interviewed regarding resident bruising and falls |
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding documentation, notifications, restorative programs, and education |
| Staff A | Homemaker Cook | Observed during food service and handwashing deficiencies |
| Dietary Manager | Dietary Service Manager | Educated staff on handwashing and hairnet use |
| Social Services Director | Social Services Director | Interviewed regarding PASARR evaluations and updates |
Inspection Report
Routine
Census: 32
Deficiencies: 0
Dec 1, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 32
Inspection Report
Abbreviated Survey
Census: 37
Deficiencies: 1
Jun 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on 06/10/2020 to determine compliance with CMS and CDC recommended practices to prepare for COVID-19.
Findings
The facility failed to ensure staff implemented infection control practices to prevent the spread of infection, specifically regarding proper use and disposal of personal protective equipment (PPE) by one staff member entering a resident's room without recommended PPE.
Deficiencies (1)
| Description |
|---|
| Staff H entered a resident's room without wearing the recommended PPE including a face shield and gown, failing to follow infection control practices. |
Report Facts
Census: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Named in infection control deficiency for not donning appropriate PPE | |
| Director of Nursing | Director of Nursing | Verified presence of used gown and stated expectations for staff infection control practices |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Mar 12, 2020
Visit Reason
Investigation of facility complaints #87290-C and #87433-C regarding quality of care and failure to provide necessary assessments for residents with condition changes.
Findings
The facility failed to provide necessary assessments for 1 of 4 residents reviewed with a condition change, specifically Resident #4. Deficiencies included incomplete documentation and inadequate communication regarding skin and wound assessments, podiatry visits, and resident condition changes.
Complaint Details
Investigation of facility complaints #87290-C and #87433-C resulted in findings of deficient quality of care related to Resident #4's assessments and documentation.
Severity Breakdown
Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide necessary assessments for Resident #4 with condition change, including incomplete skin and wound assessments and inadequate documentation of podiatry treatment. | Level D |
Report Facts
Resident census: 38
Residents reviewed: 4
Dates of relevant documentation: Oct 27, 2019
Dates of relevant documentation: Nov 18, 2019
Dates of relevant documentation: Nov 20, 2019
Dates of relevant documentation: Jan 19, 2020
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