Inspection Reports for Garnett Place

The inspection was conducted as a complaint investigation related to complaints #124879-C, #125733-C, and #123764-C at Garnett Place, an assisted living program for people with dementia.

The program failed to update service plans as needed to reflect the identified needs of tenants, specifically related to wandering, exit seeking behaviors, urinary tract infections, urinary incontinence, and toileting refusal. This deficiency pertained to 3 of 4 current tenants reviewed and 2 of 4 discharged tenants reviewed.

No regulatory insufficiencies were cited related to complaints #124879-C and #125733-C. One regulatory insufficiency was cited during the investigation of complaint #123764-C.

The inspection was conducted to investigate complaints #117522-C, #118869-C, #120657-C and to conduct a recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.

The facility was found deficient in multiple areas including medication administration errors, failure to provide supervision as trained, failure to evaluate tenant needs after significant changes, failure to revise service plans when needs changed, failure to maintain operating alarm systems on exit doors, and failure to maintain fencing around an enclosed courtyard.

The inspection was triggered by complaints #117522-C, #118869-C, and #120657-C.

The inspection was conducted as a complaint investigation into multiple complaints and incidents related to medication administration and facility safety at Garnett Place, an assisted living program for people with dementia.

The investigation found that the program failed to administer medication as prescribed to one discharged tenant, Tenant C1, and failed to have an operating alarm system connected to each exit door, potentially affecting all tenants. Additionally, the program failed to maintain the building and grounds in a safe manner, including unsecured doors and a missing fence section.

The investigation was triggered by complaints #113475-C, #115248-I, #116159-C, and #116281-C. No regulatory insufficiencies were cited for complaints #113475-C and #115248-I. The findings relate to complaints #116159-C and #116281-C.

Investigation of Complaints #112259-C and #112360-C, and Incident #112263-I at the assisted living facility.

No regulatory insufficiencies were cited during the investigation of the complaints and incident.

Investigation of Complaints #112259-C and #112360-C, and Incident #112263-I found no regulatory insufficiencies.

The inspection was conducted as a complaint investigation into multiple complaints and an incident, specifically Complaint #111312-C, Complaint #109928-C, Incident #108433-I, and Complaint #110091-C.

No regulatory insufficiencies were found for Complaints #111312-C, #109928-C, and Incident #108433-I. One regulatory insufficiency was cited related to failure to retain a copy of the occupancy agreement for 1 of 3 discharged tenants reviewed (Tenant C2).

The investigation included Complaints #111312-C, #109928-C, #110091-C and Incident #108433-I. The deficiency was cited during the investigation of Complaint #110091-C. No regulatory insufficiencies were found for the other complaints and incident.

The investigation of Complaints #98826-C, #103064-C, #103226-C and #105759-C and the recertification visit were conducted to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.

The Program failed to complete evaluations as needed with significant change, failed to follow established policies and procedures related to incident reports, failed to ensure tenants received housekeeping and laundry services as indicated in the occupancy agreement, failed to administer medications and complete treatments per physician order, failed to document nurse's notes by exception, failed to ensure staff received nurse delegated training within 30 days of employment, failed to ensure service plans were developed and updated as needed, failed to obtain signatures by all parties when service plans were updated with significant change, failed to ensure physician orders were current and medications were administered consistent with orders, and failed to have an operating door alarm on all exit doors.

The visit was complaint-related involving multiple complaints (#98826-C, #103064-C, #103226-C, #105759-C) regarding tenant care and compliance with certification for a Dedicated Dementia Specific Assisted Living Program.

The investigation was conducted as a complaint investigation related to regulatory insufficiencies at Garnett Place, an assisted living program for people with dementia.

The inspection found deficiencies in individualized service plans, staffing and safety checks. Specific tenants' service plans did not reflect their current needs or use of assistive devices. Safety checks were inconsistently documented, and staff failed to consistently monitor tenants as required.

The investigation of Complaint #87497-C resulted in regulatory insufficiencies.

Recertification visit conducted to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.

No regulatory insufficiencies were cited during the recertification visit for the Dedicated Dementia Specific Assisted Living Program.

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

There were no regulatory insufficiencies cited during the recertification visit.

Investigation of Complaint #62220-C was completed to identify regulatory insufficiencies related to the complaint during the course of the investigation.

The inspection found regulatory insufficiencies related to medication administration and service plans, including failure to follow physician orders and incomplete documentation of treatments and medications for tenants.

Complaint #62220-C was investigated and regulatory insufficiencies were identified related to medication administration and service plans.

The visit was a Final Recertification Monitoring Evaluation to determine compliance with certification for an Assisted Living Program.

No regulatory insufficiencies were found during this evaluation. The review of recertification documents and the State Fire Marshal's inspection report were accepted.

The inspection was conducted as a complaint/incident investigation regarding a report that Tenant #1 was missing approximately $500 from their apartment.

The investigation found that Tenant #1 reported missing money, an investigation was completed, a staff member tested positive on a drug test and was terminated, and no regulatory insufficiencies were identified.

The complaint involved missing money from Tenant #1's apartment. The Manager and Health Coordinator initiated an investigation and notified the police. A staff member was suspended and terminated after testing positive on a drug test. No further thefts were reported and no regulatory insufficiencies were noted.

The inspection was conducted as a complaint/incident investigation regarding allegations of potential medications, specifically Methylphenidate (Ritalin), missing from the assisted living program.

The investigation found that the program did not administer Ritalin to any tenants and no regulatory insufficiencies were identified.

Complaint/Incident Allegation: It was alleged there were potential medications, Methylphenidate (Ritalin) missing from the program. Monitoring observation found no administration of Ritalin to tenants. No regulatory insufficiency was noted.

The visit was a final recertification monitoring evaluation conducted to assess compliance with Iowa Administrative Code chapters 481—67 and 481—69 for the Assisted Living Program at Garnett Place.

No regulatory insufficiencies were found during the onsite recertification monitoring evaluation. The program was found to be in compliance with all applicable regulations, and the Assisted Living Program Certificate was issued with effective dates from May 4, 2013 through May 3, 2015.

An on-site monitoring evaluation was conducted at Garnett Place Assisted Living to complete the final recertification monitoring evaluation as required by Iowa Code and Administrative Code.

No regulatory insufficiencies were found during this evaluation. The program did not receive any regulatory insufficiencies during this certification period, and tenant satisfaction was positive.

A complaint and incident investigation was conducted at Garnett Place Assisted Living on September 16 and 24, 2009, related to allegations of missing and unaccounted medications for a tenant.

The investigation found that the program did not account for 160 tablets of Lortab 5mg/500mg and seven Duragesic patches missing from the tenant's medication drawer. The program also failed to provide administration of medications by an Iowa-licensed registered nurse or authorized agent as required, resulting in a regulatory insufficiency.

Complaint Intake numbers #25038-C, #25049-C, and #25039-I were investigated. The complaint was substantiated with a regulatory insufficiency noted in the area of medications.

An on-site monitoring evaluation was conducted at Garnett Place Retirement Community to assess compliance with assisted living program regulations as part of the recertification monitoring evaluation process.

The program was found to be in substantial compliance with regulations with no regulatory insufficiencies identified during this monitoring visit. Previous regulatory insufficiencies in medications and staffing were substantiated but have been addressed.

A complaint investigation was conducted at Garnett Place due to allegations regarding tenant care, specifically a tenant with a cut above the eye that allegedly needed stitches and the program's Registered Nurse was unaware.

The investigation found that the tenant with the injury resided in the Independent Living building, not the Assisted Living building, and no regulatory insufficiencies were identified during the investigation.

The complaint alleged that Tenant #1 had a cut above the eye needing stitches and the Registered Nurse was unaware. The complaint was investigated and found unsubstantiated as the tenant was not in the Assisted Living program.

A complaint investigation on-site visit was conducted at Garnett Place on March 26, 2008, to investigate allegations related to tenant care and medication errors.

The investigation found no regulatory insufficiencies related to tenant transfer or medication administration errors, despite several allegations. The program had substantiated regulatory insufficiencies in the area of medications during the certification period. The program did not consistently provide sufficient trained staff to meet tenant needs.

The complaint investigation involved allegations including improper tenant transfer, medication errors, falsifying medication administration records (MAR), and retaliation against staff. Some allegations were substantiated with observations of medication errors and insufficient staff training, while others had no regulatory insufficiencies noted.

An on-site re-certification monitoring evaluation was conducted to assess compliance with assisted living program regulations at Garnett Place.

No regulatory insufficiencies were found during the monitoring visit. Tenants expressed dissatisfaction with the quality of the supper meal but reported satisfaction with housekeeping, staff responsiveness, and available activities.

There were no substantiated complaints during this certification period.