Inspection Reports for Forest Plaza AL

635 Hwy. 9 East, Forest City, IA, 504361028

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Inspection Report Summary

The most recent inspection on May 27, 2025, found no deficiencies during the recertification visit. Earlier inspections showed a mixed record with some citations related to tenant evaluations, nurse reviews, staff training, medication administration, and notification procedures. Complaint investigations were mostly unsubstantiated, except for one substantiated medication administration issue in 2011 that resulted in a tenant’s hospitalization. No fines or enforcement actions were noted in recent reports, though a $500 civil penalty was issued in 2009 for a notification failure. The facility’s inspection history shows some recurring themes in staff training and tenant care documentation, but recent inspections indicate improvement.

Deficiencies (last 11 years)

Deficiencies (over 11 years) 0.9 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

80% better than Iowa average
Iowa average: 4.4 deficiencies/year

Deficiencies per year

4 3 2 1 0
2005
2007
2009
2011
2013
2015
2017
2019
2022
2023
2025

Census

Latest occupancy rate 16 residents

Based on a May 2025 inspection.

Census over time

9 18 27 36 45 54 Sep 2005 Dec 2009 Aug 2013 Nov 2017 Jun 2022 May 2025

Inspection Report

Renewal
Census: 16 Deficiencies: 0 Date: May 27, 2025

Visit Reason
The visit was a recertification inspection conducted to determine compliance with certification rules for an Assisted Living Program.

Findings
No regulatory insufficiencies were cited during the recertification visit.

Report Facts
Number of tenants without cognitive impairment: 15 Number of tenants with cognitive impairment: 1 Total census: 16

Inspection Report

Complaint Investigation
Census: 27 Deficiencies: 0 Date: Aug 29, 2023

Visit Reason
Investigation of Complaint #110251-C at Forest Plaza Assisted Living.

Complaint Details
Complaint #110251-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 impairment: 26 Number of tenants with cognitive impairment: 1 Total census: 27

Inspection Report

Renewal
Census: 30 Deficiencies: 2 Date: Jun 30, 2022

Visit Reason
The recertification visit was conducted to determine compliance with certification of an Assisted Living Program.

Findings
The program failed to evaluate a tenant's functional, cognitive, and health status as warranted by a significant change of condition and failed to develop service plans based on evaluations to meet identified needs for 1 of 3 tenants reviewed.

Deficiencies (2)
Failed to evaluate a tenant's functional, cognitive, and health status as warranted by a significant change of condition.
Failed to develop service plans based on evaluations conducted to meet the identified needs for 1 of 3 tenants reviewed.
Report Facts
Number of tenants without cognitive disorder: 30 Number of tenants with cognitive disorder: 0 Total Population of Program: 30

Employees mentioned
NameTitleContext
Registered NurseConfirmed findings on 6-30-22 at 12:23 p.m.

Inspection Report

Renewal
Census: 42 Deficiencies: 2 Date: Nov 19, 2019

Visit Reason
The inspection was conducted as a recertification to determine compliance with certification for an Assisted Living Program.

Findings
No regulatory insufficiencies were cited during the recertification for the Assisted Living Program. However, deficiencies were found related to staffing and nurse review procedures, including failure to complete timely nurse reviews and ensure staff competency within 60 days of employment.

Deficiencies (2)
The program's registered nurse failed to complete a review to ensure staff were sufficiently trained and competent within 60 days of employment.
The program failed to consistently ensure nurse reviews were completed at least every 90 days for tenants, affecting 2 of 4 tenants reviewed.
Report Facts
Number of tenants without cognitive disorder: 42 Number of tenants with cognitive disorder: 0 Total census of Assisted Living Program: 42 Staff affected by nurse delegation review deficiency: 2 Tenants affected by nurse review deficiency: 2 Date of Director of Nursing employment start: Aug 12, 2019 Date of nurse review completion for Tenant #1: Aug 30, 2019 Date of nurse review completion for Tenant #4: Oct 18, 2018

Employees mentioned
NameTitleContext
Rick BurkeManagerSigned as Laboratory Director's or Provider/Supplier Representative's signature on the report.
Director of NursingBegan employment on 8/12/19 and confirmed lack of awareness of required staff reviews.
Registered Nurse ManagerInterviewed on 11/19/19, explained she had started in August and was attempting to catch up on nurse reviews.

Inspection Report

Renewal
Census: 40 Deficiencies: 0 Date: Nov 8, 2017

Visit Reason
Recertification conducted to determine compliance with certification for an Assisted Living Program.

Findings
No regulatory insufficiencies were cited during the recertification inspection.

Inspection Report

Complaint Investigation
Census: 34 Deficiencies: 3 Date: Oct 8, 2015

Visit Reason
The inspection was conducted as a Final Complaint Investigation and Recertification Monitoring Evaluation following allegations related to structure/life safety, medication management, and tenant rights/personal care at Forest Plaza Assisted Living.

Complaint Details
Complaint #54370-C involved allegations of structure/life safety, medication management, and tenant rights/personal care. All allegations were found to be not substantiated based on observations, staff interviews, community meetings, and document reviews.
Findings
All allegations were found to be not substantiated. However, regulatory insufficiencies were identified in the areas of record checks, service plans, and food service, requiring a Plan of Correction.

Deficiencies (3)
One out of nine staff did not have a criminal history check or a child and dependent adult abuse record check on file prior to employment.
One out of four tenants reviewed did not have all assessed needs indicated within the service plan.
Three out of nine staff reviewed did not have orientation on sanitation and safe food handling before serving food to tenants.
Report Facts
Number of tenants without cognitive disorder: 33 Number of tenants with cognitive disorder: 1 Total population of program on-site: 34 Staff reviewed without criminal history check: 1 Tenants reviewed without complete service plans: 1 Staff reviewed without sanitation and safe food handling orientation: 3

Employees mentioned
NameTitleContext
Staff GPersonnel record revealed missing criminal history and abuse record checks and missing food handling orientation
Staff BPersonnel record revealed missing food handling orientation
Staff CPersonnel record revealed missing food handling orientation

Inspection Report

Monitoring
Census: 28 Deficiencies: 0 Date: Aug 19, 2013

Visit Reason
The visit was a final recertification monitoring evaluation conducted to assess compliance with Iowa Code and Administrative Code requirements for the Forest Plaza Assisted Living facility.

Findings
No regulatory insufficiencies were found during the evaluation. Tenant satisfaction was positive, housekeeping and nursing services met expectations, and the facility was clean and safe.

Report Facts
Number of tenants without cognitive disorder: 28 Number of tenants with cognitive disorder: 0 Total Population of Program at time of on-site: 28 Tenants attending community meeting: 22

Employees mentioned
NameTitleContext
Lonny SmithAdministratorAdministrator of Forest Plaza Assisted Living named in report
Hal L. ChaseRN BSN MPHMonitor conducting the evaluation
Rose BoccellaProgram CoordinatorAuthor of the cover letter for the report

Inspection Report

Complaint Investigation
Census: 31 Deficiencies: 1 Date: Aug 29, 2011

Visit Reason
The inspection was conducted as a Final Complaint & Recertification Monitoring Evaluation in response to a complaint alleging the program failed to give a tenant medication for dementia for ten days, resulting in hospitalization.

Complaint Details
Complaint 35257-C alleged the program failed to give a tenant medication for dementia for ten days, resulting in hospitalization. The complaint was substantiated based on monitoring observations and review of medication administration records.
Findings
The program did not ensure the prescription medications were available and administered consistently as ordered by the physician, leading to a regulatory insufficiency related to medication administration and monitoring.

Deficiencies (1)
Failure to ensure prescription medications were available and administered consistently as ordered by the physician.
Report Facts
Current number of tenants without cognitive disorder: 29 Current number of tenants with cognitive disorder: 2 Total Population: 31 Days medication not given: 10 Hospitalization duration: 3 Medication dosage: 4

Employees mentioned
NameTitleContext
Hal L. ChaseRN BSN MPHMonitor conducting the evaluation

Inspection Report

Monitoring
Census: 31 Deficiencies: 1 Date: Dec 23, 2009

Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to assess compliance with Iowa Administrative Code for assisted living programs, including monitoring, civil penalties, and complaints.

Findings
The program was found to have a regulatory insufficiency related to failure to notify the Department of Inspections and Appeals within 24 hours of a tenant sustaining a substantial injury. A $500 civil penalty was assessed, but the Plan of Correction was accepted.

Deficiencies (1)
The program did not notify the Department of Inspections and Appeals within twenty-four hours of any accident causing substantial injury or death, or any fire or natural disaster occurring at or near the assisted living program.
Report Facts
Civil penalty amount: 500 Tenant census: 31 Tenant census: 0 Tenant meeting attendance: 28

Employees mentioned
NameTitleContext
Lonny SmithAdministratorAdministrator of Forest Plaza Assisted Living named in report
Hal L. ChaseRN BSN MPHMonitor conducting the evaluation
Ann MartinBureau ChiefSigned the demand letter
Connie SchafferCertification CoordinatorContact person for certification questions

Inspection Report

Monitoring
Census: 35 Deficiencies: 1 Date: Oct 29, 2007

Visit Reason
The visit was a final recertification monitoring evaluation conducted to assess compliance with assisted living program regulations at Forest Plaza Assisted Living.

Complaint Details
There were no substantiated complaints during this certification period.
Findings
The evaluation found that tenants were generally satisfied with the program, staff, and services. However, a regulatory insufficiency was identified related to the lack of documented evidence of staff training and staffing plans.

Deficiencies (1)
The program did not have training and staffing plans on file and did not maintain documentation of training received by program personnel.
Report Facts
Current number of tenants without cognitive disorder: 32 Current number of tenants with cognitive disorder: 3 Total Population: 35 Tenant meeting attendance: 25

Employees mentioned
NameTitleContext
Lonny SmithProgram AdministratorNamed as program administrator
Hal ChaseRN BSN MPHMonitor conducting the evaluation
Michael StreepyRNMonitor conducting the evaluation

Inspection Report

Monitoring
Census: 34 Deficiencies: 0 Date: Sep 29, 2005

Visit Reason
An on-site monitoring evaluation was conducted at Forest Plaza Assisted Living as part of the re-certification monitoring process.

Complaint Details
There were no substantiated complaints during this certification period.
Findings
There were no regulatory insufficiencies noted during this on-site recertification visit. Tenant and family satisfaction was generally positive with minor issues raised regarding food quality and staff training.

Report Facts
Current number of tenants without cognitive disorder: 32 Current number of tenants with cognitive disorder: 2 Total Population: 34

Employees mentioned
NameTitleContext
Lonny SmithAdministratorAdministrator of Forest Plaza Assisted Living
Mary OliverLISWMonitor conducting the evaluation

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