Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 0
Mar 17, 2025
Visit Reason
Investigation of Complaint #124599-C and Complaint #125457-C at the assisted living facility.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints.
Complaint Details
Investigation of Complaint #124599-C and Complaint #125457-C found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive impairment: 14
Number of tenants with cognitive impairment: 14
Total census: 28
Inspection Report
Renewal
Census: 30
Deficiencies: 0
Aug 1, 2024
Visit Reason
The visit was conducted as a recertification to determine compliance with certification of an Assisted Living Program for People with Dementia, including investigation of Incident #119879-I.
Findings
No regulatory insufficiencies were cited during the investigation and recertification visit.
Report Facts
Number of tenants without cognitive impairment: 18
Number of tenants with cognitive impairment: 12
Total census: 30
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Oct 2, 2023
Visit Reason
Investigation of Complaint #108258-C regarding the assisted living program.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Complaint Details
Complaint #108258-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive impairment: 26
Number of tenants with cognitive impairment: 10
Total census: 36
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 5
Apr 4, 2022
Visit Reason
The inspection was conducted as a recertification to determine compliance with certification for a Dementia-Specific Assisted Living Program and to investigate Complaint #96842-C.
Findings
The program failed to evaluate tenants' functional and health status prior to occupancy and within 30 days of occupancy for 2 out of 3 tenants reviewed. Additionally, the program failed to complete evaluations when a tenant exhibited significant health changes and failed to develop service plans based on required evaluations. The program also failed to conduct nurse reviews to monitor a tenant's health status at least every 90 days for 1 of 3 tenants reviewed.
Complaint Details
The inspection included investigation of Complaint #96842-C. No regulatory insufficiencies were cited during the investigation of Incident #102765-I.
Deficiencies (5)
| Description |
|---|
| Failed to evaluate tenants' functional and health status prior to occupancy for 2 out of 3 tenants reviewed (Tenant #1, Tenant #2). |
| Failed to evaluate tenants' functional and health status within 30 days of occupancy for 2 out of 3 tenants reviewed (Tenant #1, Tenant #2). |
| Failed to complete an evaluation when a tenant exhibited a significant change in health status for 1 out of 4 discharged tenants reviewed (Tenant C1). |
| Failed to develop service plans based on the functional and health evaluations for 2 out of 3 tenants reviewed (Tenant #1, Tenant #2). |
| Failed to conduct a nurse review to monitor a tenant's health status at least every 90 days for 1 of 3 tenants reviewed (Tenant #1). |
Report Facts
Census: 24
Census: 0
Census: 24
Census: 0
Census: 6
Census: 6
Census: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Wrote an alert for the RN regarding Tenant C1's urination pattern | |
| RN #2 | Registered Nurse | Reviewed alert and failed to complete health evaluation for Tenant C1 after significant change |
| Staff A | Notified RN #2 of changes in Tenant C1's behaviors prior to hospitalization |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 0
Jan 9, 2020
Visit Reason
Investigation of Complaint #87141-C at the assisted living facility Garden View Place.
Findings
No insufficiencies were cited during the complaint investigation.
Complaint Details
Complaint #87141-C was investigated and found to have no insufficiencies.
Report Facts
Census: 28
Census: 0
Census: 3
Census: 31
Inspection Report
Renewal
Census: 31
Deficiencies: 0
Jul 17, 2019
Visit Reason
Recertification conducted to determine compliance with certification for a Dementia-Specific Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification for the Dementia-Specific Assisted Living Program.
Report Facts
Census of General Population: 24
Census of Memory Care Unit: 7
Total Census: 31
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 0
Oct 30, 2017
Visit Reason
Investigation of Incident #70773-I to assess compliance and any deficiencies related to the complaint.
Findings
No insufficiencies or deficiencies were cited during the investigation of Incident #70773-I.
Complaint Details
Investigation of Incident #70773-I found no insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 25
Number of tenants with cognitive disorder: 3
Total Population of Program at time of on-site: 28
Inspection Report
Renewal
Census: 26
Deficiencies: 5
Jun 7, 2017
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification requirements for an assisted living program.
Findings
The inspection identified regulatory insufficiencies related to program policies and procedures, medication administration, nurse delegation training, tenant evaluations, service plans, and dementia-specific education for personnel.
Deficiencies (5)
| Description |
|---|
| Program failed to consistently follow policy and procedure related to dropped medications, affecting 1 tenant. |
| Program failed to complete nurse delegation training on service plan tasks for 4 of 4 staff who completed the task. |
| Program failed to complete evaluations as needed with significant change for 2 of 3 tenant files reviewed. |
| Program failed to develop service plans based on evaluations and update service plans as needed for 3 of 3 tenant files reviewed. |
| Program failed to provide dementia-specific education and training within 30 days of employment for 4 of 5 staff files reviewed. |
Report Facts
Total census of Assisted Living Program: 26
Number of tenants without cognitive disorder: 24
Number of tenants with cognitive disorder: 2
Number of tenants affected by dropped medication deficiency: 1
Number of staff affected by nurse delegation training deficiency: 4
Number of tenant files with incomplete evaluations: 2
Number of tenant files with incomplete service plans: 3
Number of staff files lacking dementia-specific education: 4
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 0
Jan 19, 2017
Visit Reason
Investigation of Complaint #63553-C regarding the Assisted Living Program at Garden View Senior Community.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint. The census included 21 tenants without cognitive disorder and 2 tenants with cognitive disorder, totaling 23 residents on-site.
Complaint Details
Complaint #63553-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 21
Number of tenants with cognitive disorder: 2
Total population of Program at time of on-site: 23
Total census of Assisted Living Program: 23
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 6
Apr 28, 2015
Visit Reason
The inspection was conducted as a Final Recertification & Complaint/Incident Investigation Report following an investigation by the Department of Inspections and Appeals on April 28 & 29, 2015, related to medication diversion and regulatory insufficiencies at Garden View Senior Community.
Findings
The Program reported a diversion of 44 narcotic pills removed from medication cassettes and replaced with over-the-counter medications. Regulatory insufficiencies were found in program policies and procedures, service plans, food service, dementia-specific education for personnel, and structural requirements. A $500 civil penalty was assessed due to failure to comply with regulatory requirements.
Complaint Details
The complaint investigation was triggered by a diversion of 44 narcotic pills from medication cassettes. The investigation included review of tenant files, medication administration records, staff interviews, and observations. The perpetrator was not identified. The Program changed medication administration processes and was assessed a $500 civil penalty.
Deficiencies (6)
| Description |
|---|
| Program policies and procedures, including those for incident reports, were not followed, specifically regarding destruction of dropped medications. |
| Service plans were not individualized to identify tenants' needs and preferences for assistance, including failure to update plans for antibiotic treatment. |
| Food service personnel did not complete required orientation on sanitation and safe food handling or annual in-service training on food protection. |
| Dementia-specific education for program personnel was not completed as required, with several staff lacking minimum hours of continuing education. |
| Structural requirements were not met as chemicals in the dementia-specific unit were not secured in a locked cabinet. |
| Food service deficiencies included failure to check and document appropriate food temperatures during meal preparation and service. |
Report Facts
Civil penalty amount: 500
Narcotic pills diverted: 44
Census: 24
Tenants without cognitive disorder: 22
Tenants with cognitive disorder: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Observed during medication pass dropping medication and not following destruction policy. | |
| Staff A | Registered Nurse | Did not follow procedure for dropped medication; involved in medication pass observations. |
| Staff D | Observed preparing food and failed to check food temperatures. | |
| Rose Boccella | Program Coordinator | Contact person for the Department of Inspections & Appeals. |
| Randee Blietz | Executive Director | Named in the demand letter and Plan of Correction response. |
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 2
Feb 18, 2015
Visit Reason
The inspection was conducted as a complaint/incident investigation related to regulatory insufficiencies in service plans and nurse review at Garden View Senior Community.
Findings
The investigation found that the program failed to develop adequate service plans and nurse reviews for tenants, specifically Tenant #1 who eloped and was at risk due to wandering. Documentation and staff interviews revealed insufficient monitoring and safety measures for this tenant.
Complaint Details
The complaint investigation was substantiated by findings that Tenant #1 eloped and the program failed to develop a service plan and conduct a nurse review to meet the tenant's safety needs.
Deficiencies (2)
| Description |
|---|
| Failure to develop a service plan for each tenant based on evaluations and to update the plan annually or as needed, specifically for Tenant #1 who exited the building unnoticed. |
| Failure to conduct a nurse review when a tenant with impaired decision-making ability eloped and returned after an unknown length of time, specifically Tenant #1. |
Report Facts
Civil penalty amount: 1000
Reduced civil penalty amount: 650
Census: 25
Number of tenants without cognitive disorder: 22
Number of tenants with cognitive disorder: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Contact person for the Department of Inspections & Appeals regarding the report and plan of correction. |
| Jim Friberg | Acting Bureau Chief, Adult Services Bureau | Signed the demand letter. |
| Randee Blietz | Executive Director | Named in the Plan of Correction response letter. |
Inspection Report
Monitoring
Census: 21
Deficiencies: 3
May 29, 2013
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation to review the Plan of Correction in response to a Preliminary Recertification Monitoring Evaluation Report for Garden View Senior Community.
Findings
The report found multiple regulatory insufficiencies related to tenant evaluations, service plans, and medication documentation. The facility did not complete evaluations and update service plans as required, and medication administration documentation was incomplete. The Plan of Correction was accepted by the Department of Inspections and Appeals.
Deficiencies (3)
| Description |
|---|
| Evaluations were not completed as needed within 30 days of occupancy or with significant change for tenants. |
| Service plans did not reflect increased falls, sleeping troubles, suicidal ideations, swelling, bruising, pain, or other identified tenant needs and were not updated as required. |
| Medications and treatments were not documented as administered or completed, and the effectiveness of medications was not documented. |
Report Facts
Total census: 21
Number of tenants without cognitive disorder: 18
Number of tenants with cognitive disorder: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Conducted the monitoring visit |
Inspection Report
Monitoring
Census: 19
Deficiencies: 6
Jun 14, 2011
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted by the Iowa Department of Inspections and Appeals to review the Plan of Correction and regulatory compliance of Garden View Senior Community's Assisted Living Program.
Findings
The report found several regulatory insufficiencies related to tenant evaluations, service plans, nurse reviews, and food service menus. The Plan of Correction submitted by the facility was accepted by the Department of Inspections and Appeals.
Deficiencies (6)
| Description |
|---|
| A program shall evaluate each prospective tenant’s functional, cognitive and health status prior to the tenant’s signing the occupancy agreement and taking occupancy. |
| A program shall evaluate each tenant’s functional, cognitive and health status within 30 days of occupancy and annually thereafter. |
| A service plan shall be developed for each tenant based on the evaluations conducted and updated at least annually and whenever changes are needed. |
| The service plan shall be individualized and indicate tenant needs and preferences for assistance and nursing facility care if needed. |
| A nurse review shall be conducted at least every 90 days or after significant change for tenants receiving personal or health-related care. |
| Menus shall be planned to provide 100% of the daily recommended dietary allowances based on the number of meals provided by the program. |
Report Facts
Current number of tenants without cognitive disorder: 12
Current number of tenants with cognitive disorder: 1
Total Population of General Population Program: 13
Total Population of Dementia Specific Program: 6
Total Census of Assisted Living Program: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alecia Grove | Administrator | Administrator of Garden View Senior Community named in the report |
| Lori Miner | RN BSN | Monitor conducting the evaluation |
| Jim Berkley | Program Coordinator | Signed letter regarding certification |
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 3
Dec 22, 2010
Visit Reason
A complaint investigation was conducted at Garden View Senior Community due to allegations of inappropriate tenant discharge and administrative staff favoritism.
Findings
The investigation found that one tenant was inappropriately discharged but not due to favoritism. The program followed occupancy agreements and regulatory requirements. Several regulatory insufficiencies were noted related to tenant evaluations, service plans, and incident reporting.
Complaint Details
Complaint Allegation: It was alleged a tenant was inappropriately discharged and that administrative staff favoritism influenced the discharge. The investigation found no evidence of favoritism and that discharges followed policy and occupancy agreements.
Deficiencies (3)
| Description |
|---|
| Failure to evaluate each tenant's functional, cognitive, and health status within 30 days of occupancy and as needed thereafter. |
| Failure to update the service plan within 30 days of tenant's occupancy and as needed with significant changes. |
| Failure to report all accidents or unusual occurrences affecting tenants as incidents. |
Report Facts
Current number of tenants without cognitive disorder: 16
Current number of tenants with cognitive disorder: 0
Total Population of General Population Program: 16
Total Population of Dementia Specific Program: 6
Total Census of Assisted Living Program: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alecia Grove | Executive Director | Named in relation to tenant discharge and administrative decisions |
| Stephanie Cummins | Monitor | Conducted the complaint investigation |
| Jim Berkley | Program Coordinator, Adult Services Bureau | Signed cover letter for the report |
Inspection Report
Monitoring
Census: 21
Deficiencies: 4
Sep 8, 2009
Visit Reason
The on-site monitoring evaluation was conducted to assess Garden View Senior Community's compliance with Iowa Code and Administrative Code regulations related to assisted living programs, focusing on tenant evaluations, service plans, transportation, and record checks.
Findings
The report identified multiple regulatory insufficiencies including failure to complete tenant evaluations within 30 days of occupancy, inadequate individualized service plans, insufficient transportation vehicle safety equipment, and incomplete employee record checks. A $500 civil penalty was assessed and a revised Plan of Correction was accepted.
Deficiencies (4)
| Description |
|---|
| The program did not consistently complete evaluations of tenants within 30 days of occupancy and with significant changes in status. |
| The program did not individualize service plans to meet specific tenant needs or update plans with changes in tenant status. |
| The program did not maintain transportation vehicles with required safety equipment including first-aid kits, fire extinguishers, and safety triangles. |
| The program did not consistently request or document child and dependent adult abuse record checks prior to hiring employees. |
Report Facts
Civil penalty amount: 500
Reduction amount: 325
Current number of tenants without cognitive disorder: 15
Current number of tenants with cognitive disorder: 0
Total Population of General Population Program: 15
Total Population of Dementia Specific Program: 6
Total Census of Assisted Living Program: 21
Community meeting attendance: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor conducting the evaluation |
| Alecia Grove | Director | Facility director named in report |
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