Inspection Reports for Maggie’s House Assisted Living
107 E 2nd, Dewitt, IA, 527422140
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 14, 2025, found no deficiencies during the recertification visit for the Assisted Living Program. Earlier inspections generally showed a pattern of compliance with occasional deficiencies primarily related to individualized service plans and employee background checks. Complaint investigations over the years included some substantiated issues with medication administration and staff training, as well as a $500 civil penalty in 2011 for failure to notify the department about a tenant elopement and monitoring lapses. Enforcement actions included two $500 fines assessed in 2008 and 2011, with no license suspensions or revocations listed in the available reports. The facility’s inspection history shows improvement over time, with no deficiencies noted in the most recent inspections.
Deficiencies (last 11 years)
Deficiencies (over 11 years)
1.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
66% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
20 residents
Based on a January 2025 inspection.
Census over time
Inspection Report
Renewal
Census: 20
Deficiencies: 0
Date: Jan 14, 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 for the Assisted Living Program.
Inspection Report
Renewal
Census: 20
Deficiencies: 0
Date: Feb 9, 2022
Visit Reason
Recertification visit conducted to determine compliance with certification for an Assisted Living Program and to perform the onsite infection control survey.
Findings
No regulatory insufficiencies were cited during the recertification visit or the onsite infection control survey.
Report Facts
Number of tenants without cognitive disorder: 19
Number of tenants with cognitive disorder: 1
Total census: 20
Inspection Report
Renewal
Census: 17
Deficiencies: 0
Date: May 10, 2018
Visit Reason
The visit was conducted as a recertification to determine compliance with certification for an Assisted Living Program. Additionally, a complaint (#75153-C) was investigated during the visit.
Complaint Details
Complaint #75153-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the recertification visit or the complaint investigation.
Report Facts
Number of tenants without cognitive disorder: 15
Number of tenants with cognitive disorder: 2
Total census: 17
Inspection Report
Renewal
Census: 20
Deficiencies: 0
Date: Aug 24, 2016
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 of the Assisted Living Program at Maggie's House.
Report Facts
Number of tenants without cognitive disorder: 17
Number of tenants with cognitive disorder: 3
Total Population of Program at time of on-site: 20
Inspection Report
Monitoring
Census: 19
Deficiencies: 0
Date: Aug 5, 2014
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation for Maggie's House Assisted Living to review recertification documents and perform an onsite monitoring evaluation.
Findings
No regulatory insufficiencies were found during the onsite recertification monitoring evaluation. The program was accepted and the Assisted Living Program Certificate was issued.
Report Facts
Number of tenants without cognitive disorder: 16
Number of tenants with cognitive disorder: 3
Total population of program at time of on-site: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amber Meier | RN Director | Director of Maggie's House Assisted Living |
| Wendy E. Kuhse | RN BS | Monitor conducting the evaluation |
| Rose Boccella | Program Coordinator | Signed the Final Recertification Monitoring Evaluation Report |
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 0
Date: Nov 8, 2012
Visit Reason
The inspection was conducted as a final complaint/incident investigation following a report that a tenant walked out of the assisted living program and was going to a family member's house, with concerns about tenant safety and interactions.
Complaint Details
The complaint involved a tenant eloping from the program and concerns about tenant interactions and safety. The complaint was investigated with multiple staff and nurse consultant interviews and review of service plans. The complaint was not substantiated as no regulatory insufficiencies were found.
Findings
No regulatory insufficiencies were identified. The investigation found that Tenant #1 eloped but was safely returned without injury, and the program followed its missing tenant policy. The program was not dementia-specific and had audible door chimes. Staff statements and safety checks supported that the tenant was safe during the incident.
Report Facts
Number of tenants without cognitive disorder: 17
Number of tenants with cognitive disorder: 1
Total Population of Program at time of on-site: 18
Age of Tenant #1: 88
Age of Tenant #2: 84
Temperature at Davenport Airport: 47
Approximate distance traveled by Tenant #1: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Boss | RN Director | Facility director named in report header |
| Stephanie Cummins | MA | Monitor for complaint investigation |
| Margaret Kaltefleiter | RN MS | Monitor for complaint investigation |
| Jim Berkley | Program Coordinator | Author of cover letter for report |
Inspection Report
Monitoring
Census: 21
Deficiencies: 1
Date: Jul 9, 2012
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review the Plan of Correction submitted in response to a Preliminary Recertification Monitoring Evaluation Report and to evaluate compliance with regulatory requirements for Maggie's House Assisted Living.
Findings
The review found that the Plan of Correction was accepted by the Department of Inspections and Appeals. The program did not receive any regulatory insufficiencies during this certification period. Tenant satisfaction was generally positive, and staff records were reviewed with one regulatory insufficiency noted related to a pre-employment background check evaluation.
Deficiencies (1)
A prospective employee's criminal history check required further research and evaluation by the Department of Human Services to determine employment eligibility was not completed.
Report Facts
Number of tenants without cognitive disorder: 20
Number of tenants with cognitive disorder: 1
Total census: 21
Staff files reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Boss | Director & RN Manager | Facility Director named in report |
| Jim Berkley | Program Coordinator | Signed letter regarding certification |
| Stephanie Cummins | MA | Monitor for the evaluation visit |
| Margaret Kaltefleiter | RN MS | Monitor for the evaluation visit |
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 2
Date: May 2, 2012
Visit Reason
The investigation was conducted in response to complaints and incidents alleging medication administration issues, staffing shortages, failure to respond to calls, and concerns about tenant care and safety at Maggie's House Assisted Living.
Complaint Details
The complaint investigation addressed allegations of medications not administered on time, staff resignations causing shortages, failure of the RN Director to respond to calls, and tenant care concerns including falls and unmet needs. The complaints were reviewed through tenant interviews, file reviews, and staff statements. No regulatory insufficiencies were substantiated.
Findings
The investigation found no regulatory insufficiencies related to medication administration, staffing, or response to calls. Tenant files and interviews indicated adequate care and staffing levels. Some tenants had significant medical issues and falls, but no deficiencies were noted in care plans or service delivery. Structural requirements noted lack of single-action lockable entrance doors.
Deficiencies (2)
The service plan shall be individualized and indicate tenant's identified needs and preferences for assistance.
Programs shall have private dwelling units with a single-action, lockable entrance door.
Report Facts
Medication error reports: 13
Total tenants at time of visit: 20
Tenants without cognitive disorder: 19
Tenants with cognitive disorder: 1
Tenant falls for Tenant #5: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Boss | RN Director | Named in medication administration and staffing findings. |
| Stephanie Cummins | MA | Monitor for the complaint investigation. |
| Margaret Kaltefleiter | RN MS | Monitor for the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 0
Date: Feb 13, 2012
Visit Reason
The inspection was conducted as a final complaint/incident investigation following allegations related to tenant falls and staff documentation practices at Maggie's House Assisted Living.
Complaint Details
The complaint involved allegations that a tenant fell and broke a hip requiring assistance, and that a staff member rewrote documentation on an incident report to 'pass state inspection'. Both allegations were investigated with no regulatory insufficiencies noted.
Findings
No regulatory insufficiencies were identified during the investigation. The report details observations related to tenant falls and staff rewriting incident reports but found no violations.
Report Facts
Census: 19
Tenants without cognitive disorder: 18
Tenants with cognitive disorder: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Nelson | RN Director | Named as recipient of the report and Director of Maggie's House Assisted Living |
| Joyce Kix | RN | Monitor conducting the complaint/incident investigation |
| Jim Berkley | Program Coordinator | Signed cover letter for the report |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 0
Date: Oct 10, 2011
Visit Reason
The inspection was conducted as a complaint/incident investigation following allegations that Maggie's House Assisted Living did not maintain enough food in the kitchen for one week and did not have working phone services.
Complaint Details
Complaint/Incident Intake #36201-C involved allegations of inadequate food supply in the kitchen and non-working phone services. Both allegations were investigated and no regulatory insufficiencies were found.
Findings
The investigation found no regulatory insufficiencies. The kitchen had adequate meat and staples for at least one week, and tenants reported sufficient food. The phone service was temporarily out during installation of new services but tenants had individual phone service without interruption.
Report Facts
Number of tenants without cognitive disorder: 19
Number of tenants with cognitive disorder: 2
Total Population of Program at time of on-site: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Limkeman | Director | Named as facility director in complaint investigation |
| Joyce Kix | RN | Monitor conducting the complaint/incident investigation |
| Jim Berkley | Program Coordinator | Author of the cover letter transmitting the report |
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 2
Date: Jun 30, 2011
Visit Reason
The inspection was conducted as a final incident investigation following a complaint intake regarding a tenant who left the building without staff knowledge at Amber Ridge Assisted Living.
Complaint Details
Complaint intake #34765-I involved Tenant #1 leaving the building without staff knowledge on 6-28-11. The tenant had dementia and a history of elopement. The program failed to notify the department as required and had insufficient monitoring procedures.
Findings
The investigation found regulatory insufficiencies related to failure to notify the department when a tenant eloped and issues with monitoring and visual checks for the tenant. A $500 civil penalty was assessed, and a plan of correction was submitted.
Deficiencies (2)
Failure to notify the department when Tenant #1 eloped on 5-16-11.
Inadequate monitoring and visual checks for Tenant #1 who left the building without staff knowledge.
Report Facts
Civil penalty amount: 500
Days to request hearing or pay penalty: 30
Current number of tenants without cognitive disorder: 18
Current number of tenants with cognitive disorder: 2
Total population: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer West | Director | Named as facility director in relation to findings and penalty |
| Jim Berkley | Program Coordinator | Contact person for appeal and penalty payment |
| Lori Miner | RN BSN | Monitor during incident investigation |
| Margaret Kaltefleiter | RN MS | Monitor during incident investigation |
Inspection Report
Monitoring
Census: 16
Deficiencies: 1
Date: Sep 20, 2010
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 in response to previously identified regulatory insufficiencies at Amber Ridge Assisted Living.
Findings
The report found that the Plan of Correction was accepted by the Department of Inspections and Appeals. The monitoring evaluation included review of tenant files and identified a regulatory insufficiency related to individualized service plans not specifying tenant needs and preferences for assistance. Tenant satisfaction was generally positive with no issues reported regarding housekeeping or maintenance.
Deficiencies (1)
The service plan shall be individualized and shall indicate, at a minimum, the tenant’s identified needs and preferences for assistance.
Report Facts
Current number of tenants without cognitive disorder: 16
Current number of tenants with cognitive disorder: 0
Total Population: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | MA | Monitor conducting the evaluation |
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 1
Date: Sep 15, 2009
Visit Reason
An on-site visit was conducted at Amber Ridge Assisted Living on September 15, 2009, to investigate an incident involving medication administration errors related to Fentanyl patches.
Complaint Details
There were substantiated complaints during the certification period in the areas of Evaluation of Tenants, Service Plans, Nurse Review, Staffing, and Record Checks. The incident investigation focused on medication administration errors involving Fentanyl patches and a dependent adult abuse investigation was initiated.
Findings
The investigation found that the program did not accurately count or record the delivery and administration of Fentanyl patches, resulting in regulatory insufficiency for inconsistent medication administration by licensed nursing staff. A dependent adult abuse investigation and local police investigation were initiated.
Deficiencies (1)
The program did not consistently provide the administration of medications by an Iowa-licensed registered nurse or advanced registered nurse practitioner as required by regulations.
Report Facts
Current number of tenants without cognitive disorder: 20
Current number of tenants with cognitive disorder: 0
Total Population: 20
Fentanyl patches delivered on 7-27-09: 3
Fentanyl patches delivered on 7-29-09: 7
Fentanyl patches counted on 8-2-09: 7
Medication administration frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor of the incident investigation |
| Chris Nothaft | Certification Coordinator – Eastern Iowa | Reviewer of the Plan of Correction |
Inspection Report
Plan of Correction
Census: 18
Deficiencies: 5
Date: Jun 9, 2008
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to assess regulatory insufficiencies in tenant evaluation, service plans, nurse review, staffing, and record checks at Amber Ridge Assisted Living.
Findings
The report found multiple regulatory insufficiencies including inconsistent evaluation of tenants' functional and cognitive status, incomplete service plans, incomplete nurse reviews, insufficiently trained staff, and failure to obtain timely criminal history clearances for employees. The Plan of Correction was accepted and a civil penalty of $500 was assessed.
Deficiencies (5)
The program did not consistently evaluate each tenant's functional, cognitive, and health status as needed.
The program did not consistently develop individualized service plans reflecting tenants' needs.
The program did not ensure nurse reviews were completed as needed.
The program did not consistently provide sufficient trained staff to meet tenants' needs.
The program did not consistently obtain clearance from DHS for employees prior to hire when a criminal history 'hit' was revealed.
Report Facts
Civil penalty amount: 500
Number of tenants without cognitive disorder: 18
Number of tenants with cognitive disorder: 0
Total population: 18
Number of tenant interviews: 15
Number of tenant interviews: 3
Date of monitoring visit: Jun 9, 2008
Date of report: Jul 23, 2008
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | SW MA | Monitor conducting the on-site monitoring evaluation |
| Ann Martin | Bureau Chief, Adult Services Bureau | Author of the final recertification report and enforcement letter |
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 3
Date: Sep 9, 2004
Visit Reason
A complaint investigation was conducted at Amber Ridge on September 9, 2004, following substantiated complaints related to medication administration during the certification period.
Complaint Details
The complaint investigation was triggered by allegations that the program did not appropriately assess a tenant after a fall, did not provide appropriately supervised medications, and did not have appropriately trained staff administering medications. The complaint related to medication errors was substantiated.
Findings
The investigation found no regulatory insufficiency related to tenant evaluation after a fall, but identified multiple medication administration errors, inadequate medication supervision, and insufficient staff medication training and documentation. The program had a history of medication errors and implemented a plan of correction, but issues persisted including unlocked medication storage and medication errors by staff.
Deficiencies (3)
The program did not ensure medication administration was appropriately supervised and administered by the program nurse, including training and storage.
The program did not provide for appropriate medication training via Nurse Delegation, including practicum checks by the nurse, not peer to peer.
The program did not have documentation of training received by staff members.
Report Facts
Current number of tenants without cognitive disorder: 19
Current number of tenants with cognitive disorder: 0
Medication errors caught by cross-checking staff: 27
Medication doses missed or delayed for Tenant #3: 3
Insulin dose given incorrectly: 20
Staff Member #5 hire date: Jan 6, 2004
Medication course sessions attended by Staff Member #5: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Social Worker (SW) | Monitor conducting the complaint investigation |
| Staff Member #5 | Staff member involved in multiple medication errors and terminated on 8/20/04 | |
| Cathy Morel | Facility contact person named in the report |
Inspection Report
Complaint Investigation
Census: 15
Deficiencies: 1
Date: May 20, 2004
Visit Reason
A complaint investigation on-site visit was conducted at Amber Ridge to investigate allegations related to tenant assessment after a fall, retention of tenants beyond appropriate care level, medication administration without physician orders, medication setup errors, treatment without physician orders, and staff training on medication administration.
Complaint Details
The complaint investigation addressed allegations that the program did not assess a tenant after a fall, retained tenants beyond appropriate care levels, provided medication administration without physician orders, had medications not set up correctly, provided treatment without physician orders, and had inappropriately trained staff administering medications. The investigation found no substantiated regulatory insufficiencies except for medication supervision concerns.
Findings
The investigation found no regulatory insufficiencies regarding tenant assessment after falls, retention criteria, service plans, nurse review, or staff training. However, frequent medication setup errors were noted, with three documented errors since January 2004, and the program was administering medications set up by tenants' family members without formal orders. The program was developing a new medication policy to address these issues.
Deficiencies (1)
Supervision of self-medication and administration of medications shall be provided by a practitioner or the practitioner’s authorized agent in accordance with 655—subrule 6.2(5) and Iowa Code chapter 155A.
Report Facts
Current General Population ALP Census: 15
Number of tenants with dementia: 5
Documented medication errors: 3
Frequency of medication errors: 1
Complaint Intake Number: 7869
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Social Worker (SW) | Monitor conducting the complaint investigation |
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