Inspection Reports for Grand Haven Retirement Community Moments
201 East Franklin Street, Eldridge, IA, 527481311
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 28, 2025, identified a deficiency related to unauthorized access to narcotics by a new employee in training. Earlier inspections were mostly free of deficiencies, with only occasional issues noted in medication management, service plan updates, and incident reporting policies. Prior deficiencies primarily involved updating service plans to address tenant needs and ensuring proper procedures for incident reporting and medication access. Complaint investigations were generally unsubstantiated except for the recent substantiated medication access issue and a few earlier isolated findings related to policy compliance. The inspection history shows mostly consistent compliance with some isolated issues, with the most recent finding indicating a need for improved medication security controls.
Deficiencies (last 13 years)
Deficiencies (over 13 years)
0.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
86% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
15 residents
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 15
Deficiencies: 1
Date: Jul 28, 2025
Visit Reason
The inspection was conducted as an investigation into Incident #128524-M concerning medication administration and access to narcotics.
Complaint Details
The investigation was triggered by Incident #128524-M involving drug diversion discovered when a new employee in training accessed morphine without authorization. The complaint was substantiated by video evidence and staff interviews.
Findings
The program failed to ensure that only employees responsible for medication administration had access to narcotics. A new employee in training was observed on video accessing and taking morphine from the medication cart without proper authorization, violating the program's medication management policy.
Deficiencies (1)
Failed to ensure only employees responsible for medication administration had access to narcotics, allowing unauthorized access by a new employee in training.
Report Facts
Number of tenants with cognitive impairment: 15
Number of tenants without cognitive impairment: 0
Total census: 15
Inspection Report
Complaint Investigation
Census: 15
Deficiencies: 0
Date: Apr 16, 2025
Visit Reason
Investigation into Complaint #127964-C regarding the assisted living program for people with dementia.
Complaint Details
Investigation into Complaint #127964-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants with cognitive impairment: 15
Number of tenants without cognitive impairment: 0
Total census: 15
Inspection Report
Renewal
Census: 11
Deficiencies: 0
Date: Dec 12, 2024
Visit Reason
The visit was conducted as a recertification to determine compliance with certification of an Assisted Living Program for People with Dementia and to investigate Complaint #125283-C and Complaint #123716-C.
Complaint Details
Investigation of Complaint #125283-C and Complaint #123716-C was conducted with no regulatory insufficiencies found.
Findings
No regulatory insufficiencies were cited during the recertification visit or the complaint investigations.
Report Facts
Number of tenants without cognitive impairment: 1
Number of tenants with cognitive impairment: 10
Total census: 11
Inspection Report
Complaint Investigation
Census: 11
Deficiencies: 0
Date: Feb 12, 2024
Visit Reason
The inspection was conducted as an investigation of Complaint #114715-C at the assisted living program for people with dementia.
Complaint Details
Investigation of Complaint #114715-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive impairment: 2
Number of tenants with cognitive impairment: 9
Total census: 11
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 0
Date: Jan 25, 2023
Visit Reason
The visit was conducted to investigate Complaint #106605-C and Complaint #109519-C and to perform the recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Complaint Details
Investigation of Complaint #106605-C and Complaint #109519-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation and recertification visit for the Assisted Living Program for People with Dementia.
Inspection Report
Complaint Investigation
Census: 11
Deficiencies: 0
Date: Aug 26, 2020
Visit Reason
The inspection was conducted as an onsite infection control survey and investigation of Complaint #90581-C.
Complaint Details
Investigation of Complaint #90581-C found no regulatory insufficiencies.
Findings
There were no regulatory insufficiencies cited during the onsite infection control survey or the complaint investigation.
Report Facts
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 11
Total Census: 11
Inspection Report
Renewal
Census: 11
Deficiencies: 0
Date: Sep 25, 2019
Visit Reason
The visit was a recertification inspection of the Assisted Living Program for People with Dementia to assess compliance and regulatory sufficiency.
Findings
No regulatory insufficiencies were written during the recertification visit.
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 1
Date: Jun 5, 2019
Visit Reason
The investigation of Complaint #82986-C resulted in regulatory insufficiencies related to service plans and care for tenants with dementia.
Complaint Details
The complaint investigation was related to service plans and care for tenants with dementia. The investigation found regulatory insufficiencies in updating service plans and addressing tenant falls and behaviors.
Findings
The facility failed to update service plans to reflect the specific service needs of tenants, including fall interventions and management of behaviors. Multiple tenants had documented falls and other incidents that were not adequately addressed in their service plans.
Deficiencies (1)
Failure to update service plans to reflect the specific service needs of tenants, including fall interventions and management of behaviors.
Report Facts
Number of tenants without cognitive disorder: 79
Number of tenants with cognitive disorder: 4
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 11
Total Census: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Spoke with Tenant #1 about alcohol abuse and discharge criteria; reported all service plan documents were provided. |
| Manager | Manager | Reported all service plan documents for tenants were provided during interview on 6-5-19. |
Inspection Report
Renewal
Census: 92
Deficiencies: 0
Date: Sep 11, 2017
Visit Reason
The visit was a recertification inspection to determine compliance with certification for an Assisted Living Program for People with Dementia (ALP/D).
Findings
There were no regulatory insufficiencies cited during the recertification visit.
Report Facts
Number of tenants without cognitive disorder: 75
Number of tenants with cognitive disorder: 17
Total Population of Program: 92
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 0
Date: Mar 1, 2017
Visit Reason
The visit was conducted to investigate Incidents #64943-I, #65281-I, and #66237-I at the assisted living facility.
Complaint Details
Investigation of Incidents #64943-I, #65281-I, and #66237-I was completed with no regulatory insufficiencies identified.
Findings
The investigation found no regulatory insufficiencies related to the incidents reported.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 75
Number of tenants with cognitive disorder in General Population Program: 3
Total Population of General Population Program: 78
Number of tenants without cognitive disorder in Dementia-Specific Program: 1
Number of tenants with cognitive disorder in Dementia-Specific Program: 12
Total Population of Dementia-Specific Program: 13
TOTAL census of Assisted Living Program: 91
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 0
Date: Mar 9, 2016
Visit Reason
The inspection was conducted as a complaint/incident investigation following allegations regarding tenant rights violations and level of care concerns at Grand Haven Assisted Living in Eldridge, IA.
Complaint Details
Two allegations were investigated: 1) Tenant Rights - alleged failure to provide care at requested times, rude staff, and refusal to enter tenant apartments; 2) Level of Care - alleged inadequate assistance for hospice tenants. Both allegations were found not substantiated.
Findings
No regulatory insufficiencies were identified. The allegations regarding tenant rights and level of care were found to be not substantiated after review of tenant files, interviews, and observations.
Report Facts
Number of tenants without cognitive disorder: 74
Number of tenants with cognitive disorder: 7
Total Population of General Program at time of on-site: 81
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 11
Total Population of Dementia-Specific Program at time of on-site: 11
TOTAL census of Assisted Living Program: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator, Adult Services Bureau | Author of the complaint investigation report |
Inspection Report
Monitoring
Census: 93
Deficiencies: 0
Date: Sep 17, 2015
Visit Reason
The visit was conducted as 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 completed and accepted.
Report Facts
Number of tenants without cognitive disorder: 79
Number of tenants with cognitive disorder: 4
Total Population of General Program at time of on-site: 83
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 10
Total Population of Dementia-Specific Program at time of on-site: 10
TOTAL census of Assisted Living Program: 93
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Signed letter regarding the Final Recertification Monitoring Evaluation Report |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 0
Date: Jan 27, 2015
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding allegations related to admission/discharge, policy and procedure, service plans, and nurse review at Grand Haven, Eldridge, IA.
Complaint Details
The complaint investigation involved allegations of Admission/Discharge, Policy and Procedure, Service Plans, and Nurse Review. All findings were unsubstantiated. The investigation included review of tenant files, staff interviews, policy reviews, and observation of care practices.
Findings
All allegations investigated were found to be unsubstantiated. The program followed policies regarding involuntary discharge notices, service plans, and nurse reviews. No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder: 78
Number of tenants with cognitive disorder: 1
Total Population of Program at time of on-site: 79
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 10
Total Population of Program at time of on-site: 10
TOTAL census of Assisted Living Program: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Author of the report and contact person |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 4
Date: Dec 2, 2013
Visit Reason
The inspection was conducted as a final complaint/incident investigation in response to two complaint/intake allegations regarding tenant elopement and tenant injury at the Grand Haven Assisted Living Program in Eldridge, Iowa.
Complaint Details
The investigation was triggered by two complaints: Complaint #45990-I regarding a tenant elopement on 10-24-13, and Complaint #46095-C regarding a tenant fall and injury. The complaints were substantiated with detailed incident reports, staff interviews, and documentation of follow-up actions including re-education of staff and policy reviews.
Findings
The investigation found regulatory insufficiencies related to policies and procedures for door alarms and elopement prevention, as well as deficiencies in service plans for tenants who sustained falls and injuries. Multiple incidents involving tenant elopement and falls with fractures were documented, with staff responses and follow-up actions noted.
Deficiencies (4)
Policies and procedures were not followed regarding Tenant #1's elopement; staff did not check exterior alarmed doors at the start of second shift as required.
The program's policies and procedures did not meet minimum standards related to reporting incidents including allegations of dependent adult abuse.
The service plan did not reflect Tenant #3's refusal of gait belt and other possible transfer techniques or options due to refusals.
The service plan shall be individualized and indicate the tenant's identified needs and preferences for assistance, which was not met for tenants #2, #3, #4, and #5.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 79
Number of tenants with cognitive disorder in General Population Program: 4
Total Population of General Population Program: 83
Number of tenants without cognitive disorder in Dementia-Specific Program: 1
Number of tenants with cognitive disorder in Dementia-Specific Program: 11
Total Population of Dementia-Specific Program: 12
Total census of Assisted Living Program: 95
Dates of Complaint/Incident Investigation: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Monitor conducting the complaint/incident investigation |
| Dan Collins | Manager | Manager involved in tenant elopement and injury incidents |
| Jim Berkley | Program Coordinator | Signed cover letter for the report |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 0
Date: May 21, 2013
Visit Reason
The visit was conducted as a Final Complaint/Incident Investigation and Recertification Monitoring Evaluation for the Assisted Living Program at Grand Haven, Eldridge, IA, triggered by a complaint regarding alleged missing medications.
Complaint Details
The complaint alleged that medications had been diverted and that Tenant #1 had missing medications. The investigation included review of tenant files and staff files. No regulatory insufficiencies were identified related to the alleged missing medications.
Findings
The investigation found no regulatory insufficiencies related to the alleged missing medications. The program was found to be in compliance with required background checks and other regulatory requirements. Tenant and family satisfaction was generally positive.
Report Facts
Number of tenants without cognitive disorder: 68
Number of tenants with cognitive disorder: 15
Total census of Assisted Living Program: 83
Number of tenants in General Population Program: 72
Number of tenants in Dementia-Specific Program: 11
Number of tenants without cognitive disorder in General Population Program: 66
Number of tenants with cognitive disorder in General Population Program: 6
Number of tenants without cognitive disorder in Dementia-Specific Program: 2
Number of tenants with cognitive disorder in Dementia-Specific Program: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Named as monitor for the complaint/incident investigation |
| Margaret Kaltefleiter | RN MS | Named as monitor for the complaint/incident investigation |
| Daniel Collins | Manager | Facility manager named in the report |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 1
Date: Aug 1, 2012
Visit Reason
The inspection was conducted as a final complaint/incident investigation following an allegation that a staff member stole a wedding gift from a tenant to give to another staff member who was getting married.
Complaint Details
The complaint involved an allegation of theft of a wedding gift by a staff member on night shift. A dependent adult abuse investigation was conducted. The complaint was substantiated as the staff member accepted a gift from a tenant, violating policy.
Findings
The investigation found that the staff member accepted a gift from a tenant, violating the program's policy against accepting gifts from tenants. The administrator replaced the stolen gift to allow the tenant to give it to the staff member as originally planned. A regulatory insufficiency was cited related to policies and procedures on reporting incidents including dependent adult abuse.
Deficiencies (1)
Program's policies and procedures did not meet minimum standards related to reporting incidents including allegations of dependent adult abuse.
Report Facts
Number of tenants without cognitive disorder (definition): 68
Number of tenants with cognitive disorder (definition): 5
Total Population of Program at time of on-site (definition): 73
Number of tenants without cognitive disorder (dedication): 1
Number of tenants with cognitive disorder (dedication): 10
Total Population of Program at time of on-site (dedication): 11
TOTAL census of Assisted Living Program: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor of the complaint/incident investigation |
| Lori Miner | RN BSN | Monitor of the complaint/incident investigation |
| Daniel Collins | Administrator | Reported replacing the stolen gift during investigation |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 0
Date: Jun 26, 2012
Visit Reason
The inspection was conducted as a final complaint/incident investigation for the Grand Haven Retirement Community related to allegations of insufficient staffing, tenants exceeding level of care, inadequate activities in the dementia unit, and employer lunch break deductions.
Complaint Details
The complaint investigation addressed allegations of insufficient staff for breaks, tenants exceeding level of care, inadequate activities in the dementia unit, and employer deductions for lunch breaks. All allegations were found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were identified in any of the complaint areas including staffing, admission and retention criteria, activities, and employer lunch break deductions. Observations, interviews, and reviews indicated sufficient staffing, appropriate tenant care levels, adequate activities, and no regulatory issues with employee lunch breaks.
Report Facts
General Population Program tenants without cognitive disorder: 70
General Population Program tenants with cognitive disorder: 6
General Population Program total population: 76
Dementia-Specific Program tenants without cognitive disorder: 1
Dementia-Specific Program tenants with cognitive disorder: 10
Dementia-Specific Program total population: 11
Total census of Assisted Living Program: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Collins | Administrator | Administrator involved in staffing and interview observations |
| Stephanie Cummins | MA | Monitor for the complaint/incident investigation |
| Margaret Kaltefleiter | RN MS | Monitor for the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Date: Nov 16, 2011
Visit Reason
The inspection was conducted as a complaint/incident investigation following allegations related to tenant and staff interactions, including concerns about intimidation, verbal inappropriateness, assistance with toileting, response times to calls for assistance, and a tenant injury incident.
Complaint Details
The complaint involved multiple allegations: tenants being afraid of staff, verbal inappropriateness by staff, intimidation by staff, delayed response to calls for assistance, and a tenant injury involving a bruised or fractured ankle. The investigation found these allegations unsubstantiated with no regulatory insufficiencies noted.
Findings
The investigation found no regulatory insufficiencies. Interviews with tenants and staff indicated appropriate treatment and response by staff, no evidence of abuse or intimidation, and proper handling of tenant concerns. Incident reports and resident meeting minutes showed no unresolved issues. Staff had appropriate training related to dementia, abuse, toileting, and mobility.
Report Facts
Total census: 85
Alarm pendant calls: 1624
Average response time: 3.14
Alarm pendant calls: 1593
Average response time: 2.54
Alarm pendant calls: 1557
Average response time: 3.05
Alarm pendant calls: 687
Average response time: 2.56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Collins | Manager | Named as facility manager in relation to complaint investigation |
| Stephanie Cummins | MA | Monitor for complaint/incident investigation |
| Margaret Kaltefleiter | RN MS | Monitor for complaint/incident investigation |
| Jim Berkley | Program Coordinator | Author of cover letter for the complaint/incident investigation report |
Inspection Report
Monitoring
Census: 79
Deficiencies: 1
Date: Jun 27, 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 ensure compliance with regulatory requirements for the Grand Haven Retirement Community Assisted Living Program.
Findings
The monitoring evaluation found one regulatory insufficiency related to transportation services, specifically the lack of adequate seat belts and securing devices for ambulatory and wheelchair-using passengers on the program's bus. The program had no other regulatory insufficiencies during the certification period and tenant satisfaction was generally positive.
Deficiencies (1)
When transportation services are provided directly or under contract with the program: Vehicles shall have adequate seat belts and securing devices for ambulatory and wheelchair-using passengers.
Report Facts
Current number of tenants in a Dementia Specific Program (DSP) with dementia between Stages 4 and 7 on the GDS: 8
Current number of tenants without cognitive disorder: 59
Total Population: 67
Total Population of Dementia Specific Program (DSP): 12
Total Census of Assisted Living Program (ALP): 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Collins | Manager | Manager of Grand Haven Retirement Community named in the report |
| Stephanie Cummins | MA | Monitor conducting the on-site monitoring evaluation |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 0
Date: Dec 8, 2010
Visit Reason
A complaint investigation was conducted at Grand Haven Retirement Community due to allegations regarding tenant care, including transfer assistance, medication administration timeliness, and treatment of burns.
Complaint Details
The complaint alleged a tenant required two-person lift assistance but could not move independently, tenants received medications late by three to four hours, a tenant had burns from a heating pad that were not treated or charted, and a tenant who could not stand fell and fractured a hip and later died. The investigation found no regulatory insufficiencies related to these allegations.
Findings
The investigation found no regulatory insufficiencies related to tenant transfers, medication administration, or burns. Observations and staff interviews indicated appropriate care was provided, and no tenants exceeded the appropriate level of care.
Report Facts
Current number of tenants without cognitive disorder: 63
Current number of tenants with cognitive disorder: 2
Total Population of General Population Program: 65
Total Population of Dementia Specific Program: 9
Total Census of Assisted Living Program: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | MA | Monitor for the complaint investigation |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 0
Date: Aug 17, 2010
Visit Reason
The inspection was conducted as a final complaint investigation following allegations related to tenant services, including bathing, medication administration, transportation, and a tenant fall incident.
Complaint Details
The complaint alleged that a tenant paid for additional services not received due to hospitalization and requested a refund. Another allegation involved a tenant fall and subsequent care concerns. The investigation found no regulatory insufficiencies and confirmed appropriate care and follow-up actions were taken.
Findings
No regulatory insufficiencies were identified during the on-site monitoring visit. The investigation included review of tenant files, interviews with staff, and evaluation of incident reports related to tenant care and safety.
Report Facts
Current number of tenants without cognitive disorder: 63
Current number of tenants with cognitive disorder: 3
Total Population of General Population Program: 66
Total Population of Dementia Specific Program: 10
Total Census of Assisted Living Program: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Date: Apr 12, 2010
Visit Reason
The visit was conducted as an incident investigation following reports of a tenant falling multiple times between March 11 and March 14, 2010, and related concerns about the tenant's medical condition and care.
Complaint Details
The complaint involved multiple falls by a tenant aged 85 with diagnoses including hypertension, dementia, and atrial fibrillation. The tenant fell several times between March 11 and March 14, 2010, with some skin tears and pain reported. The tenant's doctor discontinued Seroquel medication due to lethargy and drooling. Staff conducted PRN nurse reviews and coordinated care appropriately. The complaint was not substantiated as no regulatory insufficiencies were identified.
Findings
The investigation found no regulatory insufficiencies. The tenant had multiple falls with no major injuries, appropriate notifications were made to the tenant's doctor and family, and the tenant received medical evaluations and care as needed. The tenant's medication was adjusted and the situation was handled appropriately by staff.
Report Facts
Current number of tenants without cognitive disorder: 66
Current number of tenants with cognitive disorder: 2
Total Population of General Population Program: 68
Total Population of Dementia Specific Program: 9
Total Census of Assisted Living Program: 77
Tenant age: 85
Incident dates: 4
PERS activation count: 6
Average PERS response time (minutes): 1.41
Maximum PERS response time (minutes): 2.24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Conducted the incident investigation |
| Chris Nothaft | Certification Coordinator – Eastern Iowa | Signed the cover letter for the incident investigation report |
| Staff #1 | Registered Nurse (RN) | Interviewed regarding tenant care and incident details |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 0
Date: Sep 29, 2009
Visit Reason
An on-site recertification visit and an incident investigation were conducted at Grand Haven on September 29, 2009, following a tenant complaint of right foot pain and injury.
Complaint Details
The complaint involved a tenant who reported right foot pain after a fall on 8-2-09. The tenant was diagnosed with a fractured 5th metatarsal. The investigation found the injury was properly evaluated and service plans updated. No regulatory insufficiencies were substantiated.
Findings
No regulatory insufficiencies were identified during the incident investigation and recertification. The tenant's injury was documented and appropriately managed, and staffing was sufficient with no complaints of lack of help.
Report Facts
Current number of tenants without cognitive disorder: 71
Current number of tenants with cognitive disorder: 1
Total Population of GPP: 72
Total Population of Dementia Specific Program (DSP): 8
Total Census of Assisted Living Program (ALP): 80
Tenant meeting attendance: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor during incident investigation |
| Chris Nothaft | Certification Coordinator – Eastern Iowa | Author of the cover letter and report enclosure |
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