Inspection Report Summary
The most recent inspection on January 15, 2025, found deficiencies related to failure to update service plans to reflect tenants’ identified needs. Earlier inspections showed a pattern of deficiencies involving medication administration, supervision, updating service plans, and maintaining safety features such as door alarms and fencing. Complaint investigations mostly resulted in findings about service plan updates, medication errors, and supervision, with no fines, immediate jeopardy findings, or license actions listed in the available reports. Most complaints were unsubstantiated or resulted in minor citations, with one substantiated case involving missing medications in 2009. The inspection history indicates ongoing challenges with documentation and tenant care planning, with some repeated issues but no clear trend of improvement or worsening over time.
Deficiencies (last 15 years)
Deficiencies (over 15 years)
1.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
13 residents
Based on a January 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 13
Deficiencies: 1
Date: Jan 15, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to update service plans as needed to reflect the identified needs of tenants, including wandering, exit seeking behaviors, urinary tract infections, urinary incontinence, and toileting refusal.
Report Facts
Number of tenants without cognitive impairment: 7
Number of tenants with cognitive impairment: 6
Total census: 13
Number of current tenants reviewed: 4
Number of discharged tenants reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mia McQuinn | Community Director | Named in relation to interview and findings about tenant care and service plans |
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 6
Date: Jul 25, 2024
Visit Reason
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.
Complaint Details
The inspection was triggered by complaints #117522-C, #118869-C, and #120657-C.
Findings
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.
Deficiencies (6)
Failed to administer medication as ordered to 1 of 5 discharged tenants reviewed (Tenant C1).
Staff failed to provide supervision based on training to 1 of 3 current tenants (Tenant #3) and 1 of 5 discharged tenants (Tenant C3).
Failed to evaluate the needs of 1 of 5 discharged tenants reviewed when needs changed (Tenant C2).
Failed to revise the service plan when needs changed for 1 of 5 discharged tenants (Tenant C2) and 1 of 3 current tenants (Tenant #1).
Failed to ensure an operating alarm system was connected and in use at all times at each exit door potentially affecting 4 of 10 tenants with cognitive impairment.
Failed to properly maintain the fencing surrounding an enclosed courtyard.
Report Facts
Number of tenants without cognitive impairment: 10
Number of tenants with cognitive impairment: 4
Total census: 14
Number of discharged tenants reviewed: 5
Number of current tenants reviewed: 3
Number of tenants with cognitive impairment potentially affected by alarm system deficiency: 4
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 3
Date: Jan 30, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failed to administer medication as prescribed to Tenant C1.
Failed to have an operating alarm system connected to each exit door in a dementia-specific program.
Failed to maintain the building and grounds in a safe, clean, and sanitary manner, including unsecured doors and missing fence section.
Report Facts
Number of tenants without cognitive disorder: 11
Number of tenants with cognitive disorder: 9
Total census: 20
Number of pills destroyed: 36
Number of discharged tenants reviewed: 1
Number of staff reeducated: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bob B | Interim Director | Signed the inspection report |
| Catie Campbell | Received immediate plan of correction for alarm system deficiency |
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 0
Date: Apr 19, 2023
Visit Reason
Investigation of Complaints #112259-C and #112360-C, and Incident #112263-I at the assisted living facility.
Complaint Details
Investigation of Complaints #112259-C and #112360-C, and Incident #112263-I found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints and incident.
Report Facts
Number of tenants without cognitive impairment: 15
Number of tenants with cognitive impairment: 8
Total census: 23
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 1
Date: Apr 11, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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).
Deficiencies (1)
Program failed to retain a copy of the occupancy agreement for 1 of 3 discharged tenants reviewed (Tenant C2).
Report Facts
Number of tenants without cognitive disorder: 15
Number of tenants with cognitive disorder: 8
Total census: 23
Discharged tenants reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Wubank | Director | Signed the plan of correction |
| Regional Nurse Specialist | Confirmed the finding on 4/11/23 at 2:35 PM |
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 10
Date: Aug 9, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (10)
Failed to complete tenant evaluations as needed with significant change for 2 of 3 current tenants and 1 of 2 discharged tenants.
Failed to follow established policies and procedures related to incident reports for 1 of 3 current tenants and 2 of 2 discharged tenants.
Failed to ensure tenants received housekeeping and laundry services as indicated in the occupancy agreement, affecting all tenants.
Failed to administer medications and complete treatments per physician order for 2 of 3 current tenants and 1 of 2 discharged tenants.
Failed to document nurse's notes by exception for 2 of 2 discharged tenants.
Failed to ensure staff received nurse delegated training on all tasks within 30 days of employment for 7 of 8 staff reviewed.
Failed to ensure service plans were developed and updated as needed to reflect identified tenant needs for 3 of 3 current tenants and 1 of 2 discharged tenants.
Failed to obtain signatures by all parties when service plans were updated with significant change for 3 of 3 current tenants and 2 of 2 discharged tenants.
Failed to ensure physician orders were current and medications were administered consistent with orders for 2 of 2 discharged tenants.
Failed to have an operating door alarm on all exit doors, specifically the lower level exit door (northeast door) was not alarmed.
Report Facts
Census: 22
Tenants without cognitive disorder: 18
Tenants with cognitive disorder: 5
Staff with delayed nurse delegated training: 7
Housekeeping documented apartment cleans: 3
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 2
Date: Feb 24, 2020
Visit Reason
The investigation was conducted as a complaint investigation related to regulatory insufficiencies at Garnett Place, an assisted living program for people with dementia.
Complaint Details
The investigation of Complaint #87497-C resulted in regulatory insufficiencies.
Findings
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.
Deficiencies (2)
The program failed to develop service plans reflecting the identified needs of tenants.
The program failed to consistently check on tenants as indicated in their service plans.
Report Facts
Number of tenants without cognitive disorder: 22
Number of tenants with cognitive disorder: 0
Number of tenants reviewed for service plans: 7
Number of tenants with safety checks reviewed: 7
Inspection Report
Renewal
Census: 27
Deficiencies: 0
Date: Jul 31, 2019
Visit Reason
Recertification visit conducted to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification visit for the Dedicated Dementia Specific Assisted Living Program.
Report Facts
Number of tenants without cognitive disorder: 27
Number of tenants without cognitive disorder in General Population: 21
Number of tenants without cognitive disorder in Memory Care Unit: 6
Number of tenants with cognitive disorder: 0
Inspection Report
Renewal
Census: 29
Deficiencies: 0
Date: Jul 24, 2017
Visit Reason
Recertification visit conducted to determine compliance with certification for an Assisted Living Program.
Findings
There were no regulatory insufficiencies cited during the recertification visit.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 18
Number of tenants with cognitive disorder in General Population Program: 0
Total Population of General Population Program: 18
Number of tenants without cognitive disorder in Dementia-Specific Program: 11
Number of tenants with cognitive disorder in Dementia-Specific Program: 0
Total Population of Dementia-Specific Program: 11
TOTAL census of Assisted Living Program: 29
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 2
Date: Nov 9, 2016
Visit Reason
Investigation of Complaint #62220-C was completed to identify regulatory insufficiencies related to the complaint during the course of the investigation.
Complaint Details
Complaint #62220-C was investigated and regulatory insufficiencies were identified related to medication administration and service plans.
Findings
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.
Deficiencies (2)
Medications were not administered as prescribed by the tenant's physician or documented correctly, including omissions of antacid anti-gas, Docusate Sodium, milk of magnesia, and Povidone-Iodine.
The program failed to develop individualized service plans that indicated tenants' identified needs and preferences for assistance.
Report Facts
Number of tenants without cognitive disorder: 21
Number of tenants with cognitive disorder: 2
Total census of Assisted Living Program: 23
Inspection Report
Monitoring
Census: 23
Deficiencies: 0
Date: Jul 14, 2015
Visit Reason
The visit was a Final Recertification Monitoring Evaluation to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were found during this evaluation. The review of recertification documents and the State Fire Marshal's inspection report were accepted.
Report Facts
Number of tenants without cognitive disorder: 23
Number of tenants with cognitive disorder: 0
Total population of program at time of on-site: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Signed the Final Recertification Monitoring Evaluation Report |
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 0
Date: Aug 14, 2014
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding a report that Tenant #1 was missing approximately $500 from their apartment.
Complaint Details
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.
Findings
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.
Report Facts
Amount missing: 500
Tenant age: 93
Census: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Margaret Kaltefleiter | RN MS | Monitor conducting the complaint/incident investigation |
| Rose Boccella | Program Coordinator | Author of the cover letter for the Final Complaint/Incident Investigation Report |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 0
Date: Jul 8, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding allegations of potential medications, specifically Methylphenidate (Ritalin), missing from the assisted living program.
Complaint Details
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.
Findings
The investigation found that the program did not administer Ritalin to any tenants and no regulatory insufficiencies were identified.
Report Facts
Total census: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor who reported findings during the on-site visit |
Inspection Report
Monitoring
Census: 24
Deficiencies: 0
Date: Apr 1, 2013
Visit Reason
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.
Findings
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.
Report Facts
Number of tenants without cognitive disorder: 24
Number of tenants with cognitive disorder: 0
Total census of Assisted Living Program: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Magaret Kaltefleiter | RN MS | Monitor conducting the final recertification monitoring evaluation |
Inspection Report
Monitoring
Census: 26
Deficiencies: 0
Date: Jun 8, 2011
Visit Reason
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.
Findings
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.
Report Facts
Current number of tenants without cognitive disorder: 26
Current number of tenants with cognitive disorder: 0
Total Population: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | MA | Monitor for the evaluation |
| Margaret Kaltefleiter | RN MS | Monitor for the evaluation |
| Rose Boccella | Program Coordinator | Author of the certification letter |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 2
Date: Sep 16, 2009
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
The program did not account for missing medications including 160 tablets of Lortab 5mg/500mg and seven Duragesic patches from the tenant's medication drawer.
The program did not provide the administration of medications by an Iowa-licensed registered nurse or authorized agent as required by regulations.
Report Facts
Current number of tenants without cognitive disorder: 27
Current number of tenants with cognitive disorder: 0
Total Population: 27
Missing tablets of Lortab 5mg/500mg: 160
Missing Duragesic patches: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor for the complaint and incident investigation |
Inspection Report
Monitoring
Census: 23
Deficiencies: 0
Date: Jun 2, 2009
Visit Reason
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.
Findings
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.
Report Facts
Current number of tenants without cognitive disorder: 23
Current number of tenants with cognitive disorder: 0
Total Population: 23
Tenant meeting attendance: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Streepy | RN | Monitor conducting the on-site monitoring evaluation |
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 0
Date: Jun 9, 2008
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Current number of tenants without cognitive disorder: 24
Current number of tenants with cognitive disorder: 0
Total Population: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Smith | Administrator | Named as facility administrator in relation to complaint investigation |
| Lincoln Newsom | RN | Monitor conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 1
Date: Mar 26, 2008
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
The program did not consistently provide sufficient trained staff available at all times to fully meet the tenants' identified needs.
Report Facts
Current number of tenants without cognitive disorder: 21
Current number of tenants with cognitive disorder: 3
Total Population: 24
Medication errors reported: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jen Smith | Director | Named as facility director in report header |
| Stephanie Cummins | SW MA | Monitor conducting the complaint investigation |
| Cindy Carpenter | RN, Health Coordinator | Signed Plan of Correction response |
Inspection Report
Monitoring
Census: 27
Deficiencies: 0
Date: Mar 29, 2005
Visit Reason
An on-site re-certification monitoring evaluation was conducted to assess compliance with assisted living program regulations at Garnett Place.
Complaint Details
There were no substantiated complaints during this certification period.
Findings
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.
Report Facts
Current number of tenants without cognitive disorder: 19
Current number of tenants with cognitive disorder: 8
Total Population: 27
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