Inspection Reports for Elm Crest Retirement Community
2108 12th Street, Harlan, IA, 515372023
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 4, 2024, found no deficiencies during the recertification visit for the Assisted Living Program. Earlier inspections showed a pattern of deficiencies mainly related to tenant evaluations, individualized service plans, and nurse reviews following changes in tenant conditions. Complaint investigations over the years were mostly unsubstantiated, with one substantiated case in 2012 involving medication administration and storage issues. Enforcement actions included a $1,000 civil penalty in 2010 for staff training and fire drill deficiencies, but no license suspensions or revocations were listed in the available reports. The facility’s record shows improvement over time, with recent inspections free of cited deficiencies.
Deficiencies (last 12 years)
Deficiencies (over 12 years)
3.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
25 residents
Based on a April 2024 inspection.
Census over time
Inspection Report
Renewal
Census: 25
Deficiencies: 0
Date: Apr 4, 2024
Visit Reason
The inspection was a recertification visit conducted to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification visit for the Assisted Living Program.
Report Facts
Number of tenants without cognitive impairment: 24
Number of tenants with cognitive impairment: 1
Total census: 25
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 0
Date: Mar 30, 2023
Visit Reason
Investigation of Complaint #104550-C at Elm Crest Retirement Community.
Complaint Details
Complaint #104550-C was investigated and found to have no regulatory insufficiencies.
Findings
There were no regulatory insufficiencies cited during the investigation of the complaint.
Report Facts
Number of tenants without cognitive disorder: 23
Number of tenants with cognitive disorder: 3
Total Population of Program at time of on-site: 26
TOTAL census of Assisted Living Program: 26
Inspection Report
Renewal
Census: 27
Deficiencies: 3
Date: Oct 21, 2021
Visit Reason
The inspection was conducted as a recertification survey of the Assisted Living Program to evaluate compliance with regulatory requirements.
Findings
The program had no regulatory insufficiencies during the onsite infection control survey, but deficiencies were cited related to evaluation of tenants, service plans, and nurse reviews. The program failed to consistently complete cognitive, health, and functional evaluations, develop service plans based on evaluations, and complete nurse reviews following significant changes in tenant conditions.
Deficiencies (3)
Failed to consistently complete cognitive, health, and functional evaluations as warranted by significant change.
Failed to develop service plans based on evaluations as warranted by significant change.
Failed to complete nurse reviews following significant changes in tenant conditions.
Report Facts
Number of tenants without cognitive disorder: 26
Number of tenants with cognitive disorder: 1
Total Population of Program at time of on-site: 27
Total census of Assisted Living Program: 27
Tenants reviewed: 3
Tenants affected by evaluation deficiency: 2
Tenants affected by service plan deficiency: 1
Tenants affected by nurse review deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Timothy J Nauslar | Administrator | Signed the statement of deficiencies and plan of correction |
| Kathy Goede | Program Manager | Signed the plan of correction |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 0
Date: Dec 27, 2018
Visit Reason
Investigation of Complaint #78664-C at Elm Crest Retirement Community.
Complaint Details
Investigation of Complaint #78664-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder: 29
Number of tenants with cognitive disorder: 3
Total Population of Program at time of on-site: 32
Inspection Report
Renewal
Census: 28
Deficiencies: 1
Date: Mar 6, 2018
Visit Reason
The recertification visit was conducted to determine compliance with certification for an Assisted Living Program.
Findings
The program failed to develop individualized service plans reflecting tenant's identified needs and preferences for assistance, specifically related to medication administration for Tenant #1.
Deficiencies (1)
The program failed to develop individualized service plans to reflect tenant's identified needs and preferences for assistance, specifically for Tenant #1's medications being crushed or dissolved in water.
Report Facts
Number of tenants without cognitive disorder: 26
Number of tenants with cognitive disorder: 2
Total Population of Program at time of on-site: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tammy Rawson | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 0
Date: Oct 18, 2017
Visit Reason
The inspection was conducted as an investigation of Incident #70758-I at the assisted living program.
Complaint Details
Investigation of Incident #70758-I; no regulatory insufficiencies were found.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #70758-I at the assisted living program.
Report Facts
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 3
Total Population of Program at time of on-site: 30
TOTAL census of Assisted Living Program: 30
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 0
Date: Jul 27, 2016
Visit Reason
The inspection was conducted as a complaint investigation regarding the environment of the program being extremely warm and water dripping from the ceiling.
Complaint Details
Complaint #61757-C alleged structure/life safety issues due to warmth and water dripping from the ceiling. Findings were not substantiated after investigation.
Findings
The complaint was found to be not substantiated. Observations and interviews revealed that the air conditioning issue was temporary and tenants were generally comfortable. A small leak was noted but did not cause significant damage. No regulatory insufficiencies were cited.
Report Facts
Number of tenants without cognitive disorder: 30
Number of tenants with cognitive disorder: 2
Total census: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Kellen | Bureau Chief, Adult Services Bureau | Signed the report letter |
| Catie Campbell | Program Coordinator, Adult Services Bureau | Mentioned as contact and enclosure signer |
Inspection Report
Monitoring
Census: 31
Deficiencies: 3
Date: Mar 21, 2016
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to determine compliance with certification for an Assisted Living Program at Elm Crest Retirement Community.
Findings
The report identified regulatory insufficiencies in the areas of Evaluation of Tenant, Service Plans, and Nurse Review. Specific deficiencies included incomplete initial evaluations by healthcare professionals, service plans not based on evaluations, and lack of documentation of medication monitoring during nurse reviews.
Deficiencies (3)
Initial evaluations of function and health were not completed by a health care professional or human service professional.
Service plans did not meet identified needs of tenants and were not based on evaluations.
90-day nurse reviews did not document monitoring of medications when tenants received program-administered prescription medications.
Report Facts
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 3
Total Population of Program at time of on-site: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Signed letter regarding the Final Recertification Monitoring Evaluation Report |
| Licensed Practical Nurse (LPN)/Director | Interviewed and confirmed completion of evaluations and nurse reviews; named in findings |
Inspection Report
Monitoring
Census: 31
Deficiencies: 7
Date: Apr 9, 2014
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted by the Iowa Department of Inspections and Appeals following a survey on April 9, 2014, to evaluate regulatory insufficiencies in areas including Occupancy Agreement, Evaluation of Tenant, Service Plans, Nurse Review, Food Service, and Staffing at Elm Crest Assisted Living Program.
Findings
The report identified multiple regulatory insufficiencies including incomplete occupancy agreements, inadequate tenant evaluations, incomplete service plans, lack of nurse reviews following significant changes, insufficient staff training on food safety and nurse delegation, and missing documentation of staff competency. The program was required to submit a Plan of Correction to address these deficiencies.
Deficiencies (7)
Occupancy agreements did not contain required information such as tenant-landlord law application and 90-day notice of program cessation.
Tenant evaluations were incomplete, lacking vital signs, body system reviews, and timely nurse reviews after significant changes.
Service plans did not meet identified tenant needs, lacked identification of interventions, and were not based on evaluations.
Nurse reviews were not completed following significant changes in tenant conditions and did not assess or document health status adequately.
Staff training records lacked documentation of annual in-service training on food protection and safe food handling.
RN #1 had not provided training or completed delegations for staff to determine competency in care provision.
The program's registered nurse had not completed training on regulations for assisted living and did not document competency of direct care staff.
Report Facts
Number of tenants at time of on-site visit: 31
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 3
Number of tenants interviewed: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator, Adult Services Bureau | Author of the cover letter for the Final Recertification Monitoring Evaluation Report |
| Lori Miner | RN BSN, Monitor | Conducted the monitoring visit on April 9, 2014 |
| RN #1 | Registered Nurse, Director of Nursing | Delegating nurse for the assisted living program; involved in tenant evaluations and staff training |
| Staff #2 | Medication Manager | Involved in medication administration and incident documentation |
| Staff #5 | Medication Manager | Interviewed regarding food service and medication management |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 2
Date: Sep 27, 2012
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding medication management discrepancies at Elm Crest Retirement Community.
Complaint Details
The complaint investigation was substantiated based on findings of missing Tramadol tablets and improper medication administration and storage practices.
Findings
The investigation found an undetermined amount of Tramadol 50mg tablets prescribed to two tenants were unaccounted for and not recorded as given in the Medication Administration Records. The program initiated an investigation and a plan to count medications at shift changes. A regulatory insufficiency was cited related to medication administration and storage requirements.
Deficiencies (2)
Medications were not properly accounted for; Tramadol tablets were missing and not recorded in the MARs.
Medications must be administered by licensed nurses or under proper delegation and kept in locked containers inaccessible to unauthorized persons.
Report Facts
Total census: 30
Tenants without cognitive disorder: 28
Tenants with cognitive disorder: 2
Tramadol tablets unaccounted for: 23
Tramadol tablets unaccounted for: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Signed cover letter for the Final Complaint/Incident Investigation Report |
| Hal L. Chase | RN BSN MPH | Monitor for the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 0
Date: Nov 1, 2011
Visit Reason
The inspection was conducted as a complaint/incident investigation following a report that a tenant was bitten by a bat in their apartment.
Complaint Details
The complaint involved Tenant #1 being bitten by a bat. The tenant was alert and received medical treatment including a tetanus shot. The bat was tested negative for rabies. No regulatory insufficiencies were identified related to the incident.
Findings
The investigation found no regulatory insufficiencies. The tenant was bitten by a bat, received a tetanus shot, and the bat tested negative for rabies. The maintenance director repaired a hole in the bathroom ceiling that was initially suspected as a bat entry point, but no bats were found after the incident.
Report Facts
Number of tenants without cognitive disorder: 26
Number of tenants with cognitive disorder: 3
Total census of Assisted Living Program: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Hansen | RN Clinical Manager | Named as recipient of report and clinical manager of the facility |
| Jim Berkley | Program Coordinator | Signed the cover letter for the report |
| Lori Miner | RN BSN | Monitor conducting the complaint/incident investigation |
Inspection Report
Monitoring
Census: 30
Deficiencies: 6
Date: Oct 19, 2011
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review the Plan of Correction in response to a Preliminary Recertification Monitoring Evaluation Report for Elm Crest Assisted Living Program.
Findings
The program did not receive any regulatory insufficiencies during this certification period. Observations included tenant file reviews revealing some incomplete functional, cognitive, and health evaluations and service plans not fully supported by evaluations. The Plan of Correction was accepted by the Department of Inspections and Appeals.
Deficiencies (6)
Tenant #1's annual functional and health evaluations were not completed.
Tenant #2's functional, cognitive, and health evaluations were not completed with a change in status.
Tenant #3's functional, cognitive, and health evaluations with a change in status were not completed.
Tenant #1's annual service plan was not supported by a functional and health evaluation.
Tenant #2's service plan was not supported by functional and health evaluations.
Tenant #3's service plan was not updated to reflect interventions related to wandering and elopement.
Report Facts
Number of tenants without cognitive disorder: 26
Number of tenants with cognitive disorder: 4
Total census: 30
Number of tenants attending community meeting: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Hansen | Administrator | Administrator of Elm Crest Assisted Living Program |
| Hal L. Chase | RN BSN MPH | Monitor conducting the evaluation |
| Jim Berkley | Program Coordinator | Signed letter regarding certification |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 0
Date: Dec 22, 2010
Visit Reason
The inspection was conducted as a final incident investigation following a report that Tenant #1 lost his/her wallet, which was later returned missing a credit card, an expired driver's license, and cash. The investigation was to determine the circumstances and any regulatory insufficiencies.
Complaint Details
The complaint involved Tenant #1 losing a wallet that was returned missing a credit card, an expired driver's license, and $6.00 to $7.00 in cash. Police and staff interviews were conducted, and the tenant and family member were interviewed. No regulatory insufficiencies were substantiated.
Findings
The investigation found no regulatory insufficiencies. The tenant reported the wallet lost, and staff and police interviews were conducted. The tenant's family member reported no unusual charges on the credit card and that a new card was issued. The tenant was unaware of missing items or the wallet being returned.
Report Facts
Current number of tenants without cognitive disorder: 24
Current number of tenants with cognitive disorder: 2
Total Population: 26
Cash missing: 6.5
Cash given to tenant: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the investigation |
Inspection Report
Monitoring
Census: 29
Deficiencies: 2
Date: Jan 6, 2010
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted at Elm Crest Retirement Community to assess regulatory compliance in staffing and structural requirements.
Findings
The report identified regulatory insufficiencies related to staff training and fire drill procedures, resulting in a $1,000 civil penalty. The Plan of Correction was accepted but the request for reconsideration was denied due to unsatisfactory fire drills conducted during sleeping hours.
Deficiencies (2)
Personnel files lacked documentation of nurse delegated training for personal and health related cares given to tenants.
The program did not conduct emergency egress and relocation drills at least six times per year on a bimonthly basis, with not less than two drills conducted during the night when tenants are sleeping.
Report Facts
Civil penalty amount: 1000
Reduced penalty amount: 650
Number of tenants without cognitive disorder: 26
Number of tenants with cognitive disorder: 3
Total population: 29
Number of fire drills conducted: 7
Number of silent fire drills during sleeping hours: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the evaluation |
| Ann Martin | Bureau Chief, Adult Services Bureau | Author of the demand letter and report conclusion |
| Tamara Halvorson | Certification Coordinator | Contact person for questions regarding the letter and report |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 5
Date: Oct 27, 2008
Visit Reason
A complaint investigation on-site visit was conducted at Elm Crest Retirement Community on October 27, 2008, in response to Complaint #20466-C regarding regulatory insufficiencies and tenant care concerns.
Complaint Details
Complaint 20466-C alleged the program call system was malfunctioning over a 2 month period and completely unusable for about 3 weeks. The complaint also alleged that during this time Tenant #1 had fallen and was on the floor for 90 minutes.
Findings
The investigation found multiple regulatory insufficiencies related to tenant evaluation, service plans, nurse review, and staffing. Specific tenant cases revealed inconsistent evaluations and documentation, and a malfunctioning call system was noted. No regulatory insufficiencies were noted related to staffing beyond the call system issue.
Deficiencies (5)
The program did not consistently ensure evaluation of each tenant’s functional, cognitive, and health status was completed as needed.
The program did not consistently ensure a service plan would be developed for each tenant based on evaluations and designed to meet individual tenant needs.
The program did not consistently ensure the service plan would be individualized and indicate tenant’s identified needs and requests for assistance.
The program did not consistently ensure a registered nurse would assess and document the health status of each tenant and monitor progress on previous recommendations.
The program call system was malfunctioning over a 2 month period and unusable for about 3 weeks, delaying tenant assistance.
Report Facts
Current number of tenants with dementia or cognitive disorder: 9
Current number of tenants without cognitive disorder: 22
Total Population: 31
Complaint investigation date: Oct 27, 2008
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Jarrell | Administrator | Administrator of Elm Crest Retirement Community named in the complaint investigation report |
| Michael Streepy | RN | Monitor conducting the complaint investigation |
| Tamara Halvorson | ASB Lead Certification Coordinator | Signed letter accepting Plan of Correction |
Inspection Report
Monitoring
Census: 25
Deficiencies: 9
Date: Dec 4, 2007
Visit Reason
An on-site monitoring evaluation was conducted at Elm Crest Retirement Community to assess compliance with assisted living program regulations and to evaluate tenant care and program operations.
Findings
The program was found to have multiple regulatory insufficiencies including incomplete functional and cognitive evaluations, incomplete service plans, medication administration issues, lack of staff training documentation, and inadequate food handling training. A plan of correction was submitted addressing these deficiencies with timelines for staff re-education and monitoring.
Deficiencies (9)
The program did not consistently complete functional, health and cognitive evaluations when a change in condition existed.
The program did not consistently develop service plans based on required evaluations.
The program did not ensure all persons who develop the service plan sign the plan.
The program did not apply an acceptable standard of practice in administration of medications.
The program did not consistently document training of Medication Managers in insulin administration and supervision.
The program did not ensure the registered nurse assessed and documented health status of each tenant appropriately.
The program did not provide orientation on sanitation and safe food handling prior to staff handling food and did not provide annual in-service training.
The program did not ensure all personnel received training appropriate to assigned tasks and maintain documentation of training.
The program did not ensure all personnel employed by a dementia-specific program received a minimum of six hours of dementia-specific education and training.
Report Facts
Current number of tenants without cognitive disorder: 19
Current number of tenants with cognitive disorder: 6
Total Population: 25
Tenant meeting attendance: 17
Hours of dementia specific education: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Streepy | RN Monitor | Conducted monitoring evaluation |
| Ann Martin | RN Monitor | Conducted monitoring evaluation |
| Leslie Fries | RN Clinical Manager | Provided nurse review and corrective action letter |
Report
Nov 13, 2025
Report
Nov 14, 2024
Report
Nov 14, 2024
Report
Jul 21, 2024
Report
Oct 5, 2023
Report
Aug 25, 2022
Viewing
Loading inspection reports...
