Inspection Reports for Golden Horizons
800 Byron Godbersen Drive, Ida Grove, IA, 51445
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 24, 2025, found no deficiencies during the recertification visit. Earlier inspections also consistently showed no regulatory insufficiencies, reflecting a stable compliance record in recent years. Prior to this period of compliance, inspections identified issues mainly related to medication administration, nurse reviews, staff training, occupancy agreements, and documentation. Several complaint investigations were substantiated in earlier years, resulting in fines ranging from $500 to $3,000, but no enforcement actions such as license suspensions or immediate jeopardy findings were listed in the available reports. The inspection history indicates significant improvement over time, with recent inspections free of deficiencies after a period of multiple citations and penalties.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
2.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
34% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
29 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 29
Deficiencies: 0
Date: Sep 24, 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.
Inspection Report
Renewal
Census: 27
Deficiencies: 0
Date: Aug 2, 2023
Visit Reason
The visit was conducted as a recertification to determine compliance with certification rules 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: 27
Number of tenants with cognitive impairment: 0
Total census: 27
Inspection Report
Renewal
Census: 24
Deficiencies: 0
Date: Aug 14, 2019
Visit Reason
Recertification conducted to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification for the Assisted Living Program.
Report Facts
Number of tenants without cognitive disorder: 21
Number of tenants with cognitive disorder: 3
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 0
Date: Sep 20, 2018
Visit Reason
The inspection was conducted as an investigation of Complaint #77720-C at the assisted living program.
Complaint Details
Investigation of Complaint #77720-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Report Facts
Number of tenants without cognitive disorder: 25
Number of tenants with cognitive disorder: 2
Total Population of Program at time of on-site: 27
Inspection Report
Renewal
Census: 27
Deficiencies: 0
Date: Aug 1, 2017
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 inspection for the Assisted Living Program.
Report Facts
Number of tenants without cognitive disorder: 24
Number of tenants with cognitive disorder: 3
Total Population of Program at time of on-site: 27
TOTAL census of Assisted Living Program: 27
Inspection Report
Monitoring
Census: 26
Deficiencies: 0
Date: Jul 28, 2015
Visit Reason
The visit was a Final Recertification Monitoring Evaluation to determine compliance with certification of an Assisted Living Program at Golden Horizons, Ida Grove, IA.
Findings
No regulatory insufficiencies were found during this evaluation. The recertification documents were accepted, and the State Fire Marshal's inspection report and Facility Engineer's approval of evacuation plans were received.
Report Facts
Number of tenants without cognitive disorder: 25
Number of tenants with cognitive disorder: 1
Total Population of Program at time of on-site: 26
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 3
Date: Sep 30, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding allegations that the Housing Manager treated staff members and tenants rudely and disrespectfully, making threatening statements.
Complaint Details
The complaint alleged the Housing Manager treated staff and tenants rudely and disrespectfully, making threatening statements. The investigation included interviews with staff and tenants, observations of interactions, and review of records. The complaint was partially substantiated with findings of rude and disrespectful behavior and failure to promote tenant autonomy, but no regulatory insufficiency was found for the rule violation related to tenant rights.
Findings
The investigation found a deviation from the requirements of the rules but did not meet the standards for a regulatory insufficiency. Multiple tenants and staff reported rude and disrespectful interactions involving the Housing Manager, including use of profanity and heated arguments, but no physical threats or intimidation were substantiated. The Housing Manager failed to promote tenant autonomy by involving a Power of Attorney without tenant permission. Additionally, a regulatory insufficiency was identified related to the evaluation of a tenant's cognitive status.
Deficiencies (3)
A deviation from the requirements of the rules was found but did not meet the standards for regulatory insufficiency under rule 67.10(3).
Failure to complete a cognitive evaluation for Tenant #5 after a noted change in cognitive status.
Failure to promote Tenant #2's autonomy by contacting Power of Attorney for Financial Purposes without tenant permission during the 90 day service plan review.
Report Facts
Census: 22
Tenant without cognitive disorder: 21
Tenant with cognitive disorder: 1
Complaint/Incident Intake Number: 45381
Fee charged: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Johnson | Housing Manager | Named in multiple findings related to rude and disrespectful treatment of tenants and staff, failure to promote tenant autonomy |
| Jim Berkley | Program Coordinator | Author of cover letter enclosing the Final Complaint/Incident Investigation Report |
| Maribeth Freland | RN | Monitor conducting the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 2
Date: Jun 18, 2013
Visit Reason
The inspection was a final revisit to recertification and complaint/incident investigation for Golden Horizons Assisted Living, triggered by complaint intake #41148-CR2. The visit was conducted to assess regulatory insufficiencies related to occupancy agreements, compliance with plan of correction, and other regulatory requirements.
Complaint Details
Complaint intake #41148-CR2 triggered the investigation. The complaint/incident investigator made observations related to occupancy agreements, service plans, nurse review, staffing, medications, policies and procedures, record checks, and compliance with the plan of correction. The complaint was substantiated with findings of regulatory insufficiencies in occupancy agreements and failure to follow the plan of correction.
Findings
The program failed to comply with regulatory requirements in occupancy agreements and compliance with the plan of correction. Several occupancy agreements were incomplete with blank spaces and missing information. The program also failed to follow the previously submitted plan of correction. No regulatory insufficiencies were noted in evaluation, nurse review, medications, policies and procedures, or record checks during the revisit. Staff demonstrated training on medications and hand washing. A $500 civil penalty was assessed.
Deficiencies (2)
Occupancy agreements were incomplete with blank spaces and missing tenant information.
Failure to follow the previously submitted Plan of Correction related to occupancy agreements and policies and procedures.
Report Facts
Civil penalty amount: 500
Reduced civil penalty amount: 325
Census: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Johnson | Administrator | Administrator of Golden Horizons Assisted Living named in the report. |
| Lori Miner | RN BSN | Monitor for the revisit to recertification and complaint/incident investigation. |
| Jim Berkley | Program Coordinator | Contact person for questions regarding the report and civil penalty. |
| Jim Friberg | Acting Bureau Chief, Adult Services Bureau | Signed the demand letter. |
Inspection Report
Re-Inspection
Census: 22
Deficiencies: 7
Date: Mar 4, 2013
Visit Reason
Final revisit to recertification and complaint/incident investigation following regulatory insufficiencies identified in service plan, nurse review, staffing, medications, policies and procedures, and compliance with plan of correction.
Complaint Details
Complaint/incident investigation conducted on March 4 and 5, 2013, substantiated repeated regulatory insufficiencies in service plans, nurse review, staffing, medications, policies and procedures, and record checks.
Findings
The program failed to comply with regulatory requirements in multiple areas including individualized service plans, nurse reviews, staff training, medication administration, and occupancy agreements. A $3,000 civil penalty was assessed due to repeated regulatory insufficiencies.
Deficiencies (7)
Failure to individualize service plans and update based on evaluations for several tenants.
Incomplete and untimely nurse reviews for multiple tenants.
Staff failure to demonstrate competency on medications and medical/personal care; lack of documented training.
Failure to follow medication administration policies and professional standards.
Occupancy agreements not signed prior to admission and not updated to comply with Iowa law.
Failure to complete background checks prior to hire for some staff.
Failure to follow plan of correction and lack of documentation for audits, training, and incident reports.
Report Facts
Civil penalty amount: 3000
Reduced civil penalty amount: 1950
Census: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Contact for appeal and civil penalty payment |
| Lori Miner | RN BSN | Monitor for complaint/incident investigation |
| Ann Martin | Bureau Chief, Adult Services Bureau | Author of demand letter |
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 7
Date: Oct 17, 2012
Visit Reason
The inspection was conducted as a Final Recertification Monitoring Evaluation and Complaint/Incident Investigation for Golden Horizons Assisted Living in response to regulatory insufficiencies and a complaint regarding medication errors and staffing concerns.
Complaint Details
The complaint investigation was related to alleged medication errors due to untrained staff members. The investigation confirmed medication errors and deficiencies in staff training and medication administration procedures.
Findings
The report identified regulatory insufficiencies in tenant evaluations, service plans, nurse reviews, staffing, medication administration, policies and procedures, and record checks. Medication errors were documented, and staff training and documentation were found lacking. The program failed to comply with regulatory requirements, resulting in a civil penalty.
Deficiencies (7)
Failure to perform nurse reviews on four tenants and staffing and medication concerns.
Failure to follow record check requirements for three staff members.
Service plans were not based on evaluations, failed to meet tenant needs, and did not indicate nursing facility preferences.
Clinical records lacked documentation of nurse reviews every 90 days.
Medication errors occurred due to staff not being trained and failure to follow medication administration procedures.
Policies and procedures were not followed, including medication administration and incident reporting.
Background checks for staff were incomplete or missing prior to hire.
Report Facts
Civil penalty amount: 2000
Reduced penalty amount: 1300
Number of tenants at time of inspection: 19
Dates of monitoring visit: October 17 and 18, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Temple | Administrator | Administrator of Golden Horizons Assisted Living named in the report. |
| Lori Miner | RN BSN | Monitor conducting the evaluation. |
| Jim Berkley | Program Coordinator | Contact person for appeals and hearings related to the report. |
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 7
Date: Aug 16, 2011
Visit Reason
A complaint investigation on-site visit was conducted at Golden Horizons Assisted Living on August 16, 2011, to assess regulatory insufficiencies related to Medications, Nurse Review, Food Service, Staffing, Transportation, Structural Requirements, and Background Checks.
Complaint Details
Complaint investigation was substantiated with findings of regulatory insufficiencies in multiple areas including medications, nurse review, food service, staffing, transportation, structural requirements, and background checks.
Findings
The investigation found multiple regulatory insufficiencies including improper medication administration, incomplete nurse reviews, inadequate food service documentation, insufficient staff training and nurse delegation, transportation safety issues, and incomplete background checks. The program was assessed a $500 civil penalty and submitted a Plan of Correction.
Deficiencies (7)
Medication pass observed without staff washing or sanitizing hands; medications not administered according to accepted professional standards.
Nurse reviews were incomplete or not conducted with changes in tenant conditions as required.
Menus lacked dietitian signature and documentation of serving sizes; therapeutic diets not properly prescribed or documented.
Staff lacked training on nurse delegation and dependent adult abuse; incomplete documentation of training.
Transportation vehicle lacked fire extinguisher and safety triangles; driver license requirements not fully met.
No stationary eyewash stations in building as required; program staff unfamiliar with fire drill requirements.
Incomplete documentation of criminal background checks and dependent adult abuse checks for staff prior to employment.
Report Facts
Civil penalty amount: 500
Total tenants: 18
Tenants without cognitive disorder: 16
Tenants with cognitive disorder: 2
Plan of Correction submission date: October 3, 2011 (date mentioned but not numeric)
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Temple | Administrator | Administrator of Golden Horizons Assisted Living named in report. |
| Lori Miner | RN BSN | Monitor conducting the complaint investigation. |
| Jim Berkley | Program Coordinator | Contact person for appeals and civil penalty payment. |
| Doran Pruisner | Facility Engineer | Reported on structural requirements and fire safety. |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter and report conclusion. |
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