Inspection Report Summary
The most recent inspection on May 28, 2025, identified deficiencies related to tenant care and safety, including failure to provide appropriate care for a tenant who died unexpectedly and inadequate management of inappropriate tenant behavior. Earlier inspections showed a pattern of deficiencies involving service plan updates, safety measures such as door alarms, and staff training, particularly in dementia-specific care. Complaint investigations were mostly unsubstantiated except for the most recent one, which substantiated issues with care and supervision. Enforcement actions included past fines of $2,500 and $10,000 with conditional operation certificates in earlier years, but no enforcement actions were listed in the most recent reports. The facility’s inspection history shows ongoing challenges with care planning and safety protocols, with some improvements in complaint outcomes but persistent areas needing attention.
Deficiencies (last 14 years)
Deficiencies (over 14 years)
3.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
39 residents
Based on a May 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 2
Date: May 28, 2025
Visit Reason
The inspection was conducted in response to investigations of Complaints #125098-C and #126308-C, as well as Incident #128790-I, focusing on tenant care and safety concerns.
Complaint Details
The visit was complaint-related, investigating Incident #128790-I and Complaints #125098-C and #126308-C. The investigation found no regulatory insufficiencies related to Incident #128790-I but identified deficiencies during the complaint investigations.
Findings
The facility failed to provide appropriate care and treatment for one tenant who died unexpectedly, including failure to adequately respond to symptoms indicating a possible stroke. Additionally, the program failed to timely and adequately address inappropriate sexual behavior by another tenant, with delays in updating service plans and insufficient monitoring.
Deficiencies (2)
Failure to provide appropriate care and treatment for Tenant C1, who died unexpectedly after a fall and medication error without timely recognition of stroke symptoms.
Failure to adequately address and manage inappropriate sexual behavior by Tenant #7, including delayed updates to service plans and insufficient supervision.
Report Facts
Total census: 39
Number of tenants without cognitive impairment: 6
Number of tenants with cognitive impairment: 33
Tenant C1 age: 89
Tenant #7 age: 84
Tenant C3 age: 88
Tenant #2 age: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Documented medication error and symptoms of Tenant C1; involved in care on 11/16/24. | |
| Staff B | Reported observations of Tenant C1's weakness and inappropriate sexual behavior of Tenant #7. | |
| Staff D | Reported observations of Tenant C1's condition and notified RN. | |
| Staff E | Reported witnessing inappropriate sexual behavior by Tenant #7. | |
| Staff F | Reported witnessing inappropriate sexual behavior by Tenant #7. | |
| Registered Nurse | RN | Responded to medication error, assessed Tenant C1, confirmed death, and communicated with PCP and medical examiner. |
| Primary Care Provider | PCP | Notified post-mortem about Tenant C1's symptoms; indicated earlier notification could have changed care. |
| Linn County Medical Examiner | Medical Examiner | Assessed Tenant C1 post-mortem and determined cause of death. |
| Executive Director | ED | Confirmed staff delegation and knowledge of incidents; submitted Plan of Correction. |
| Licensed Practical Nurse | LPN | Provided information on service plan updates and staff instructions regarding Tenant #7. |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Date: Nov 4, 2024
Visit Reason
Investigation into Complaint #123709-C regarding the assisted living program for people with dementia.
Complaint Details
Investigation into Complaint #123709-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: 39
Total census: 41
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Date: Sep 26, 2024
Visit Reason
The inspection was conducted to investigate Incident #123134-I and to perform a recertification visit to determine compliance with certification rules for an Assisted Living Program for People with Dementia.
Complaint Details
The visit was triggered by a complaint investigation of Incident #123134-I. The report details the investigation and findings related to the incident involving Tenant #3 exiting the facility unalarmed.
Findings
The facility failed to ensure an operating alarm system was connected to each exit door in the dementia-specific program, affecting one of three tenants reviewed. The investigation revealed that the front vestibule doors lacked an alarm system, allowing a tenant to exit unalarmed.
Deficiencies (1)
An operating alarm system was not connected to each exit door in the dementia-specific program, violating Life Safety - Emergency Policies / Structure requirements.
Report Facts
Number of tenants without cognitive impairment: 1
Number of tenants with cognitive impairment: 43
Total census: 44
Incident date: 81924
Inspection date: 92624
Global Deterioration Score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bella Curtis | Executive Director | Named in the Plan of Correction submission and interview during investigation |
| Assistant Director of Nursing | Assessed Tenant #3 during the investigation |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Date: Aug 15, 2024
Visit Reason
The inspection was conducted as an investigation of Incident #118268-I at the assisted living program for people with dementia.
Complaint Details
Investigation of Incident #118268-I found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #118268-I.
Report Facts
Number of tenants without cognitive impairment: 1
Number of tenants with cognitive impairment: 40
Total census: 41
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 3
Date: Aug 28, 2023
Visit Reason
The inspection was conducted to investigate incidents involving tenant elopement and an attempted self-harm event at Meadowview Memory Care Village.
Complaint Details
The investigation was triggered by incidents #110585-I and #113325-I involving Tenant #1's elopement and Tenant C1's attempted self-harm. No regulatory insufficiencies were cited related to Incident #110880-I.
Findings
The program failed to follow established policies and procedures related to door alarms and nurse notification, resulting in an elopement of Tenant #1 and inadequate nurse notification for Tenant C1's attempted self-harm incident. Additionally, service plans were not updated timely or signed as required for both tenants.
Deficiencies (3)
Failure to follow established policies and procedures related to door alarms and nurse notification, leading to Tenant #1's elopement and inadequate nurse notification for Tenant C1.
Failure to update service plans timely when tenant needs changed for Tenant #1 and Tenant C1.
Failure to obtain signed service plans for Tenant C1.
Report Facts
Total census: 34
Tenants without cognitive impairment: 5
Tenants with cognitive impairment: 29
Incident Report Date: May 23, 2023
Incident Report Date: Jan 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in the finding related to failure to respond appropriately to door alarms and elopement of Tenant #1 | |
| Staff B | Named in the finding related to failure to respond appropriately to door alarms during Tenant #1's elopement | |
| Staff C1 | Discharged tenant involved in attempted self-harm incident | |
| Staff D | Named in the finding related to failure to notify nurse of Tenant C1's behavior and oxygen saturation changes | |
| Executive Director | Provided statements and confirmed findings related to incidents and service plans |
Inspection Report
Annual Inspection
Census: 25
Deficiencies: 5
Date: Apr 14, 2022
Visit Reason
The inspection was a recertification visit conducted to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Findings
The Program failed to have incident reports signed by the staff who completed the reports, failed to follow its policy and procedure related to incident reports for 4 of 5 tenants reviewed, failed to complete nurse delegated training for 2 of 6 staff within 60 days of employment, failed to ensure background checks were valid within 30 days for 1 of 6 staff, and failed to update service plans as needed to reflect current needs of 4 of 4 tenants reviewed.
Deficiencies (5)
Incident reports were not signed by the staff who completed the reports.
Program failed to follow its policy and procedure related to completion of incident reports for 4 of 5 tenants reviewed.
Failed to complete nurse delegated training for 2 of 6 staff within 60 days of employment.
Failed to ensure background checks were valid within 30 days for 1 of 6 staff reviewed.
Failed to update service plans as needed to reflect current needs of 4 of 4 tenants reviewed.
Report Facts
Census: 25
Incident reports missing signatures: 14
Staff missing nurse delegated training: 2
Staff with invalid background check: 1
Tenants with outdated service plans: 4
Weight loss: 24.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Did not receive nurse delegated training within 60 days of employment | |
| Staff D | Did not receive nurse delegated training within 60 days of employment | |
| Staff A | Background check was not valid within 30 days of hire date | |
| Staff F | Interviewed regarding tenants' sexual relationship and behaviors | |
| Staff E | Interviewed regarding tenant behaviors and incidents | |
| Staff G | Completed witness statement for incident involving Tenant #5 | |
| Staff H | Completed incident report for Tenant #5 | |
| Nurse Consultant | Interviewed regarding incident report forms and staff training |
Inspection Report
Renewal
Census: 40
Deficiencies: 2
Date: Mar 11, 2020
Visit Reason
The inspection was a recertification visit to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Findings
The inspection found regulatory insufficiencies related to individualized service plans for tenants and dementia-specific education for personnel. Several tenants' service plans did not reflect their actual needs or treatments, and some staff did not receive the required dementia-specific training within 30 days of employment.
Deficiencies (2)
Service plans were not individualized and did not reflect the identified needs of 4 of 5 tenants reviewed, including failure to reflect assistance with medications, treatments, and physical therapy discontinuation.
Dementia-specific education for personnel was not met as 4 of 8 staff reviewed did not receive a minimum of eight hours of dementia-specific education and training within 30 days of employment.
Report Facts
Number of tenants with cognitive disorder: 40
Number of tenants without cognitive disorder: 0
Number of tenants reviewed for service plans: 5
Number of staff reviewed for dementia training: 8
Number of staff not meeting dementia training requirement: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Sherzer | Executive Director | Signed the Plan of Correction letter dated March 27, 2020 |
| Director of Nursing | Mentioned in relation to discontinuation of physical therapy services and re-education on service plans | |
| Assistant Director of Nursing | Mentioned in relation to re-education on service plans |
Inspection Report
Monitoring
Census: 46
Deficiencies: 1
Date: Oct 29, 2019
Visit Reason
The visit was conducted as a monitoring investigation into regulatory insufficiency related to the admission and retention criteria for tenants at Meadowview Memory Care Village.
Findings
The program failed to discharge one tenant who exceeded the level of care due to physical aggression. Multiple staff reported aggressive behaviors by Tenant #1, including hitting, kicking, punching, and biting staff during care activities. The program planned to discharge the tenant due to these issues.
Deficiencies (1)
Failure to discharge a tenant who exceeded the level of care due to physical aggression and safety concerns for staff.
Report Facts
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 45
Total Census: 46
Date survey completed: Oct 29, 2019
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Date: Apr 18, 2019
Visit Reason
Investigation of Complaint #81961-C at Meadowview Memory Care Village.
Complaint Details
Complaint #81961-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Report Facts
Number of tenants without cognitive disorder: 2
Number of tenants with cognitive disorder: 39
Total Census: 42
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 0
Date: Feb 18, 2019
Visit Reason
Investigation of Incident #81330-I at the Assisted Living Program for People with Dementia.
Complaint Details
Investigation of Incident #81330-I; no regulatory insufficiencies found.
Findings
No regulatory insufficiencies were identified during the investigation of Incident #81330-I.
Report Facts
Number of tenants without cognitive disorder: 3
Number of tenants with cognitive disorder: 43
Total Census: 46
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 0
Date: Oct 18, 2018
Visit Reason
Investigation of Complaints #78562-C and 79112-C at Meadowview Memory Care Village.
Complaint Details
Complaints #78562-C and 79112-C were investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints.
Report Facts
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 50
Total Census: 51
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 5
Date: Sep 26, 2018
Visit Reason
The investigation of Complaint #77741-C was conducted to assess regulatory compliance related to tenant rights and care at Meadowview Memory Care Village.
Complaint Details
Investigation of Complaint #77741-C revealed incidents involving tenants #5 and #6 including incidents of undress and altercations. The complaint was substantiated with findings of regulatory insufficiencies.
Findings
The investigation found multiple regulatory insufficiencies including failure to provide adequate care and treatment for tenants, inadequate staffing training on pull cord response, and failure to administer medications as prescribed. Several incidents involving tenants were documented, including incidents of undress and altercations between tenants.
Deficiencies (5)
Program failed to provide services, care, and treatment that were adequate and appropriate for 2 of 6 tenants reviewed.
Program failed to provide services in accordance with training regarding pull cord response and resetting for 2 of 5 tenants reviewed.
Program failed to administer medications and treatments as prescribed for 5 of 6 tenants reviewed.
Program failed to complete evaluations as needed with significant change for 6 of 6 tenants reviewed.
Program failed to update service plans within 30 days and as needed with significant change for 6 of 6 tenants reviewed.
Report Facts
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 50
Total Census: 51
Number of tenants reviewed for care and treatment adequacy: 6
Number of tenants reviewed for pull cord response: 5
Number of tenants reviewed for medication administration: 6
Number of tenants reviewed for evaluations: 6
Number of tenants reviewed for service plans: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tiffany Bunting | Community Director | Signed the Plan of Correction letter describing corrective actions |
Inspection Report
Renewal
Census: 45
Deficiencies: 0
Date: Feb 8, 2018
Visit Reason
The visit was conducted as a recertification to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Findings
There were no regulatory insufficiencies cited during the recertification visit.
Report Facts
Number of tenants with cognitive disorder: 45
Number of tenants without cognitive disorder: 0
Inspection Report
Monitoring
Census: 57
Deficiencies: 0
Date: Feb 11, 2016
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation to determine compliance with certification for an Assisted Living Program at Meadowview Memory Care Village.
Findings
No regulatory insufficiencies were found during the evaluation. The review of recertification documents was completed and accepted, and the State Fire Marshal's inspection and Facility Engineer's approval of evacuation plans were received.
Report Facts
Number of tenants with cognitive disorder: 57
Total Population of Program at time of on-site: 57
TOTAL census of Assisted Living Program: 57
Inspection Report
Monitoring
Census: 49
Deficiencies: 0
Date: Mar 5, 2014
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review recertification documents and evaluate the Assisted Living Program for compliance with Iowa Code and Administrative Code.
Findings
No regulatory insufficiencies were found during the onsite recertification monitoring evaluation. The program was described as well-managed with satisfied tenants and no concerns regarding housekeeping, safety, or services.
Report Facts
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 48
Total Population of Program at time of on-site: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Conducted the monitoring visit |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
Date: Sep 11, 2012
Visit Reason
The inspection was conducted as a Final Complaint/Incident Investigation based on complaints alleging tenant abuse, neglect, and staffing issues at Meadowview Memory Care Village.
Complaint Details
The complaint investigation involved three complaint/incident intake numbers: 40153-I, 40193-C, and 40548-C. Allegations included tenant combative behavior resulting in injury, aggressive certified nurse aides forcing tenants to stand, and short staffing on weekends leading to neglect. The investigation found no substantiated regulatory insufficiencies related to abuse or neglect. Medication administration documentation issues were noted but not cited as deficiencies.
Findings
The investigation reviewed multiple allegations including tenant combative behavior, bruising, staffing adequacy, and staff interactions with tenants. No regulatory insufficiencies were found related to abuse or neglect, and staffing was found to be adequate. Some medication administration documentation issues were noted but did not rise to regulatory insufficiency.
Report Facts
Census: 47
Number of tenants with cognitive disorder: 46
Number of tenants without cognitive disorder: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Travis Senters | Director | Named as Director of Meadowview Memory Care Village and involved in investigation |
| Stephanie Cummins | MA | Monitor for the complaint investigation |
| Margaret Kaltefleiter | RN MS | Monitor for the complaint investigation |
Inspection Report
Monitoring
Census: 43
Deficiencies: 1
Date: Oct 31, 2011
Visit Reason
The visit was a Final Recertification Monitoring Evaluation to review the Plan of Correction and assess compliance with regulatory requirements for the Assisted Living Program at Meadow View Memory Care Village.
Findings
The program did not receive any regulatory insufficiencies during this certification period. The monitoring visit included review of tenant files, observations of tenant care and safety, and evaluation of staff interactions. One regulatory insufficiency was noted related to failure to notify the department within 24 hours when a tenant eloped from the program.
Deficiencies (1)
Program notification to the department was not made within 24 hours when a tenant eloped from the program.
Report Facts
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 42
Total Population of Program at time of on-site: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Margaret Kaltefleiter | RN MS | Monitor conducting the evaluation |
Inspection Report
Monitoring
Census: 46
Deficiencies: 0
Date: Jul 11, 2011
Visit Reason
The visit was an on-site monitoring investigation conducted on July 11, 2011, following an incident intake related to a tenant found lying on the floor with injuries at MeadowView Memory Care Village.
Complaint Details
The visit was complaint-related due to an incident allegation involving a tenant found on the floor with injuries. The complaint was investigated and found to have no regulatory insufficiencies.
Findings
The investigation found no regulatory insufficiencies. The tenant was transported to a hospital with a diagnosis of an acute subdural hematoma after being found on the floor with back pain and nausea. Staff responded appropriately, and the tenant was discharged from the program on June 7, 2011.
Report Facts
Total Population of Dementia Specific Program: 46
Tenant Age: 92
Incident Dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Conducted the on-site monitoring visit |
| Staff Member #1 | Interviewed staff who found the tenant and provided care during the incident | |
| Staff Member #2 | Licensed Practical Nurse | Interviewed nurse who completed narrative notes and followed up with hospital |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Date: Feb 3, 2011
Visit Reason
A complaint investigation on-site visit was conducted at Meadow View Memory Care Village in Cedar Rapids on February 3, 2011, to investigate allegations related to inadequate meal quantity resulting in weight loss among tenants.
Complaint Details
The complaint alleged the program failed to serve meals adequate in quantity, resulting in weight loss of five pounds or greater for multiple tenants. The complaint was investigated and found to be unsubstantiated with no regulatory insufficiencies noted.
Findings
The investigation found that eight tenants showed significant weight loss, but the program had initiated interventions such as nutritional supplements and a snack cart. Tenant interviews and record reviews indicated no complaints about food quality or quantity, and no regulatory insufficiencies were identified.
Report Facts
Total Population of Dementia Specific Program: 44
Total Census of Assisted Living Program: 44
Tenants with weight loss (Aug 2010 - Oct 2010): 8
Tenants with weight loss (Aug 2010 - Jan 2011): 11
Tenant records reviewed: 4
Tenant interviews conducted: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor who made observations during the complaint investigation |
| Maribeth Freland | RN | Monitor who made observations during the complaint investigation |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Date: Aug 16, 2010
Visit Reason
The visit was conducted as a complaint and incident investigation at Meadowview Memory Care Village following complaint intakes 29874-C, 29736-I, and 29645-I.
Complaint Details
Complaint Allegation 29871-C alleged tenants should be at a higher level of care; no insufficiency found. Incident Allegation 29736-I involved a tenant elopement; no insufficiency found. Complaint Allegation 29874-C alleged staff were told not to document certain things; no insufficiency found. Complaint Allegation about tenant pets and care found no insufficiency. Incident Allegation 29645-I involved missing tenant property; no insufficiency found.
Findings
The investigation found no regulatory insufficiencies related to the complaints. Observations included tenant eligibility for program retention, an elopement incident, documentation practices, pet care, and missing tenant property, with no violations noted.
Report Facts
Complaint Intake Numbers: 3
Tenant Count: 44
Tenants with dementia: 43
Tenants without cognitive disorder: 1
Tenant records reviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor conducting the investigation |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 2
Date: Mar 24, 2010
Visit Reason
An on-site incident investigation and recertification monitoring evaluation was conducted at Meadowview Memory Care Village on March 24 & 25, 2010, in response to an incident involving a tenant found on the floor and related care concerns.
Complaint Details
The complaint involved a tenant found on the floor on 1-21-10. The tenant was able to move all extremities without pain and was sent to the hospital for evaluation of compression deformities. The complaint was investigated and found to be unsubstantiated with no regulatory insufficiencies noted.
Findings
The investigation found no substantiated regulatory insufficiencies during this certification period. The tenant involved had a compression deformity and was managed appropriately with updated service plans and medical orders. Staff responded promptly to the incident and the tenant's care needs were addressed.
Deficiencies (2)
The service plan did not include the required 15 minute safety checks for Tenant #2.
The service plan for Tenant #1 did not include the two hour safety checks at the time of the fall.
Report Facts
Total Population of DSP: 39
Total Census of ALP: 39
Tenant Age: 93
Tenant Age: 87
Fentanyl Patch Dosage: 25
Fentanyl Patch Dosage: 50
Fentanyl Patch Dosage: 75
Fentanyl Patch Frequency Hours: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Conducted the incident investigation and monitoring evaluation |
| Chris Nothaft | Certification Coordinator – Eastern Iowa | Signed the final recertification monitoring evaluation and incident investigation report |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 1
Date: Dec 14, 2009
Visit Reason
A complaint investigation was conducted at Meadowview Memory Care Village on December 14, 15, and 16, 2009, due to allegations including a tenant being hospitalized following a fall and lack of food or drink, a tenant having a urinary tract infection and becoming septic, and a tenant having bruises.
Complaint Details
Complaint allegations included a tenant hospitalized after a fall with no food or drink for four to five days, a tenant with a urinary tract infection who became septic, and a tenant with bruises. The investigation reviewed tenant files and nurse notes, finding some regulatory insufficiencies but no confirmation of dependent adult abuse.
Findings
The investigation found regulatory insufficiencies related to the program's failure to assess and document tenant health status, make appropriate recommendations and referrals, and monitor progress. Several tenants' files were reviewed with findings of inconsistent nurse reviews and documentation. Bruises on a tenant were noted but dependent adult abuse was not confirmed. The Plan of Correction was accepted.
Deficiencies (1)
The program did not assess and document the health status of each tenant, make recommendations and referrals as appropriate, and monitor progress on previous recommendations if there are changes in health status.
Report Facts
Number of tenants in Dementia Specific Program: 39
Number of tenants without cognitive disorder: 2
Total Population: 41
Fine amount: 2500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Named as monitor for the complaint investigation |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Date: Oct 27, 2009
Visit Reason
A complaint investigation on-site visit was conducted at MeadowView Memory Care Village on October 27 & 28, 2009 to investigate regulatory insufficiencies related to dementia-specific assisted living program compliance.
Complaint Details
Complaint investigation was substantiated with findings of regulatory insufficiency related to dementia-specific education. The complaint investigator made observations regarding tenant care and staff actions during the investigation.
Findings
The program did not adequately complete the dementia-specific education for program personnel, resulting in a regulatory insufficiency. Interviews confirmed staff had given showers to tenants despite refusals on some occasions.
Deficiencies (1)
The program did not adequately complete the dementia-specific education for program personnel.
Report Facts
Current number of tenants with dementia or cognitive disorder: 39
Current number of tenants without cognitive disorder: 1
Total Population: 40
Fine amount: 2500
Plan of Correction due timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Streepy | RN | Monitor for the complaint investigation |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 2
Date: Jun 30, 2008
Visit Reason
A complaint investigation on-site revisit was conducted at Meadowview Memory Care Village on June 30, 2008, to monitor compliance with prior complaints and regulatory requirements.
Complaint Details
The complaint investigation included substantiated complaints in areas such as Evaluation of Tenants, Criteria for Exclusion of Tenants, Service Plans, Medications, Nurse Review, Staffing, and Other. Previous complaint investigations resulted in fines and sanctions, but the final revisit found no regulatory insufficiencies.
Findings
The final complaint investigation revisit report found no regulatory insufficiencies and the program was in full compliance with Iowa Code and Administrative Code. The program was issued a full certificate effective July 30, 2008, through February 7, 2010, with sanctions discontinued and allowed to admit new tenants.
Deficiencies (2)
During the May 8 and 9, 2008 revisit, the program received a regulatory insufficiency for not updating the tenant’s service plan with a change of condition.
During the May 8 and 9, 2008 revisit, the program received a regulatory insufficiency for not consistently following their plan of correction in regards to service plans, which were not individualized and did not indicate tenant needs and requests.
Report Facts
Current number of tenants in Dementia Specific Program: 30
Current number of tenants without cognitive disorder: 1
Total Population: 31
Fine amount: 1500
Fine amount: 8000
Fine amount: 10000
Fine amount: 2500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Thomsen | Administrator | Named as facility administrator in relation to the complaint investigation |
| Ann Martin | Bureau Chief | Signed the final complaint investigation revisit report |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 8
Date: May 8, 2008
Visit Reason
A complaint investigation on-site revisit was conducted at Meadowview Memory Care Village on May 8-9, 2008 to investigate regulatory insufficiencies and complaints regarding assisted living programs.
Complaint Details
The complaint investigation was substantiated with findings of regulatory insufficiencies in service plans, medication administration, tenant evaluations, and Plan of Correction implementation. Previous complaints had resulted in fines and sanctions.
Findings
The program failed to comprehensively follow regulations, resulting in regulatory insufficiencies in areas including service plans, medication protocols, and other requirements. The facility received a conditional certificate with sanctions and a civil penalty of $2,500.00 was assessed.
Deficiencies (8)
Regulatory insufficiency related to not completing functional, cognitive and health evaluations for certain tenants.
Regulatory insufficiency related to not excluding a tenant requiring a higher level of care.
Regulatory insufficiency related to not completing or signing service plans for tenants.
Regulatory insufficiency related to not developing a service plan by a health care professional in consultation with tenant and representatives.
Regulatory insufficiency related to not following an acceptable medication protocol for multiple tenants.
Regulatory insufficiency related to not having written documentation showing signature, date and time of physician orders for certain tenants.
Regulatory insufficiency related to not implementing the Plan of Correction submitted.
Regulatory insufficiency related to not updating the tenant’s service plan with a change in condition.
Report Facts
Civil penalty amount: 2500
Number of tenants in dementia specific program: 29
Number of tenants without cognitive disorder: 1
Total population: 30
Number of new tenants allowed per month: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal Chase | RN BSN MPH | Monitor during the complaint investigation. |
| Lincoln Newsom | RN | Monitor during the complaint investigation. |
| Ann Martin | Bureau Chief, Adult Services Bureau | Author of the sanction and penalty letter. |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 13
Date: Jan 8, 2008
Visit Reason
A complaint investigation, a first and second complaint revisit investigation, and a recertification on-site visit were conducted at Meadowview Memory Care Village on January 8-10, 2008, to investigate multiple complaints and regulatory insufficiencies.
Complaint Details
The complaint investigation involved multiple complaint intakes (#14760, #14987, #13455R, #12444R2) alleging choking spells not evaluated, failure to exclude tenants needing higher care, failure to provide service plans, medication errors, staffing shortages, failure to make rounds, elopement risks, and improper hiring practices. The complaints were substantiated with regulatory insufficiencies found.
Findings
The program was found to have multiple regulatory insufficiencies including failure to complete functional, cognitive, and health evaluations; failure to exclude tenants requiring a higher level of care; failure to develop individualized service plans; medication administration issues; inadequate nurse review; staffing and training deficiencies; and life safety concerns. The program was sanctioned with a conditional operation certificate, a civil penalty of $10,000, and required to submit a Plan of Correction.
Deficiencies (13)
Failure to complete functional, cognitive, and health evaluations when a change in condition existed for multiple tenants.
Failure to exclude tenants who no longer qualify for the level of care the program provides.
Failure to develop and update individualized service plans for tenants as required.
Medication and treatment documentation indicated medications and treatments were not charted as given; staff did not document refusals or reasons.
Failure to consistently follow an acceptable medication protocol.
Failure to ensure physician orders and treatments were consistently signed, dated, and timed.
Staffing issues including allegations of insufficient staff to meet tenant needs and improper placement of Certified Nursing Assistants in charge of shifts.
Failure to make routine rounds on tenants with impaired memory and failure to provide requested water to a tenant with a urinary tract infection.
Failure to have sufficiently trained staff available at all times to meet tenant needs.
Failure to follow written emergency policies and procedures related to life safety and elopement risk.
Failure to conduct applicable employee record checks prior to employment.
Failure to establish standards that allow flexibility in design promoting social model of service delivery.
Failure to implement the Plan of Correction related to evaluation of tenants, service plan updates, and obtaining signatures.
Report Facts
Complaint Intake Numbers: 4
Civil Penalty Amount: 10000
Census: 41
Dates of Investigation: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor for the investigation |
| Lincoln Newsom | RN | Monitor for the investigation |
| Ann Martin | Bureau Chief, Adult Services Bureau | Author of the sanction and penalty letter |
| Mark Thomsen | Administrator | Facility administrator named in report |
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