Inspection Reports for Midlands Living Center LLC
2452 North Broadway, Council Bluffs, IA, 515030434
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 2, 2025 found the facility in substantial compliance with no deficiencies. Earlier inspections showed a pattern of deficiencies primarily related to infection control, care planning, and resident rights, including issues with catheter care, comprehensive care plans, and dignity in resident treatment. Several complaint investigations were substantiated, such as failure to maintain infection control during catheter care and inadequate care plan development, but enforcement actions like fines or license suspensions were not listed in the available reports. Most complaint investigations were unsubstantiated or resulted in the facility being found in substantial compliance. The facility’s record shows some improvement over time, with more recent inspections indicating fewer deficiencies and accepted plans of correction restoring compliance.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
7% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
68 residents
Based on a April 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 2, 2025
Visit Reason
A complaint investigation for complaints #128681-C, #128607-C, and #129491-C was conducted from August 27, 2025 to September 2, 2025.
Complaint Details
Complaint investigation for complaints #128681-C, #128607-C, and #129491-C; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 9, 2025
Visit Reason
The document reflects acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, leading to certification in compliance effective May 9, 2025.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction; no specific deficiencies or severity levels are detailed in the report.
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Date: Apr 24, 2025
Visit Reason
The inspection was conducted based on investigation of complaints #127576-C and #127950-C from April 22 to April 24, 2025. Complaint #127576-C was substantiated while complaint #127950-C was not substantiated.
Complaint Details
Complaint #127576-C was substantiated. Complaint #127950-C was not substantiated.
Findings
The facility failed to maintain appropriate infection control practices for one of four residents reviewed (Resident #6), specifically related to catheter care procedures. Observations revealed improper hand hygiene, reuse of dropped gauze, and improper handling of catheter supplies by staff during catheter care.
Deficiencies (1)
Failure to maintain appropriate infection control practices during catheter care for Resident #6, including improper hand hygiene and reuse of contaminated gauze.
Report Facts
Census: 68
Complaint numbers investigated: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide (CNA) | Named in infection control deficiency related to catheter care |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Observed catheter care and provided instruction during deficiency |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 16, 2025
Visit Reason
The document reflects acceptance of a credible allegation of substantial compliance and the facility's Plan of Correction, leading to certification in compliance effective January 16, 2025.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction submitted, resulting in certification of compliance.
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 5
Date: Jan 15, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #123789-C, #124240-C, and #125312-C from January 12 to January 15, 2025.
Complaint Details
Complaint #125312-C was substantiated as stated in the report.
Findings
The facility was found deficient in developing and implementing comprehensive care plans, meeting professional standards for services provided, ensuring free of accident hazards, and infection prevention and control. Several residents' care plans lacked necessary interventions and monitoring, and the facility failed to follow physician orders and maintain proper policies.
Deficiencies (5)
Failure to develop a comprehensive person-centered care plan for residents, including Enhanced Barrier Precautions (EBP) for 3 of 5 residents reviewed.
Failure to update care plans for 2 of 17 residents, including lack of interventions for edema and antidepressant medications.
Failure to follow physician's orders for 3 of 17 residents, including medication administration and monitoring blood pressures.
Failure to provide safe transfer techniques and supervision to prevent accidents for 1 of 3 residents reviewed.
Failure to establish and maintain an infection prevention and control program including proper use of Enhanced Barrier Precautions (EBP).
Report Facts
Residents reviewed for Enhanced Barrier Precautions: 5
Census: 63
Residents with care plan deficiencies: 2
Residents with medication order issues: 3
Residents reviewed for accident hazards: 3
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 11, 2024
Visit Reason
The document reflects acceptance of a credible allegation of substantial compliance and approval of the Plan of Correction for the facility.
Findings
The facility will be certified in compliance effective October 11, 2024, based on acceptance of the credible allegation and Plan of Correction. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 1
Date: Sep 30, 2024
Visit Reason
The inspection was conducted as an investigation of complaints #123426-C and facility reported incidents #123580-I and #123650-I from September 27 through September 30, 2024.
Complaint Details
Complaint #123426-C was not substantiated. Facility reported incidents #123580-I and #123650-I were substantiated.
Findings
The facility was found to have failed to ensure that Resident #2 was treated with dignity, as evidenced by staff interactions captured on video and staff statements. The complaint #123426-C was not substantiated, but the reported incidents #123580-I and #123650-I were substantiated.
Deficiencies (1)
Failure to ensure Resident #2 was treated with dignity and respect, violating Resident Rights/Exercise of Rights.
Report Facts
Resident census: 72
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 8, 2024
Visit Reason
A complaint investigation for complaint #119421-C and facility reported incident #118256-I was conducted on July 7, 2024 through July 8, 2024.
Complaint Details
Complaint investigation for complaint #119421-C and facility reported incident #118256-I.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 8, 2024
Visit Reason
The document reflects acceptance of a credible allegation of substantial compliance and the facility's Plan of Correction, leading to certification in compliance effective January 8, 2024.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction submitted, resulting in certification of compliance.
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 4
Date: Dec 18, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey from December 18, 2023 to December 21, 2023.
Findings
The facility was found deficient in coordinating PASARR assessments, revising comprehensive care plans, infection prevention and control practices, and dependent adult abuse training. Specific issues included failure to update PASARR for a resident, incomplete care plan revisions for anticoagulant medication side effects, inadequate infection prevention practices during blood glucose monitoring, and insufficient dependent adult abuse training for staff.
Deficiencies (4)
Failure to coordinate PASARR assessments and refer residents for pre-admission screening and resident review.
Failure to revise and update comprehensive care plans to include side effects to watch for with anticoagulant medication in 1 of 17 residents reviewed.
Failure to provide appropriate infection prevention practices when completing blood glucose monitoring and disposing of used needles.
Failure to provide dependent adult abuse training within 6 months of hire for 1 of 5 employees reviewed.
Report Facts
Census: 69
Residents reviewed for care plans: 17
Employees reviewed for abuse training: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Dietary Aide | Identified as having incomplete dependent adult abuse training and no longer employed at the facility. |
| Staff E | Observed improperly handling medication administration and infection control procedures. | |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding expectations for infection control and medication administration. |
| Staff G | Assistant Director of Nursing (ADON) | Provided statements regarding hand hygiene expectations. |
| Administrator | Administrator | Provided statements regarding training courses and facility policies. |
| Staff D | Interviewed regarding PASARR completion and expectations. | |
| Staff B | Interviewed regarding PASARR policy. | |
| Staff C | Interviewed regarding PASARR policy. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 5, 2023
Visit Reason
A complaint investigation for complaints #109208-C and #111640-C was conducted from August 31, 2023 through September 5, 2023.
Complaint Details
Complaint investigation for complaints #109208-C and #111640-C; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 30, 2022
Visit Reason
The document is a plan of correction submitted by Midlands Living Center LLC following a survey to address deficiencies and demonstrate compliance.
Findings
The facility was found to be in compliance based on acceptance of a credible allegation of compliance and the submitted plan of correction, effective 12/30/22.
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 9
Date: Nov 22, 2022
Visit Reason
A Federal Monitoring Survey was conducted by CMS from November 14 through November 22, 2022, following an Iowa Department of Inspection and Appeals survey on October 6, 2022. The survey investigated multiple complaints including resident self-administration of medications, privacy/confidentiality of records, grievances, mobility, accident hazards, psychotropic medication use, therapeutic diets, safe environment, and water availability.
Complaint Details
The survey was complaint-driven, investigating multiple complaints identified by Iowa Department of Inspection and Appeals, including issues with resident self-administered medications, privacy violations, grievance process deficiencies, mobility and accident hazards, psychotropic medication use, therapeutic diet provision, environmental safety, and water availability.
Findings
The facility was found deficient in several areas including failure to ensure clinically appropriate self-administration of medications, lack of privacy during personal care, inadequate grievance procedures and resident awareness, failure to provide restorative nursing services, unsafe environmental conditions, improper monitoring of psychotropic medications, failure to serve therapeutic diets as ordered, and failure to maintain potable water supply. The census was 75 residents at the time of inspection.
Deficiencies (9)
Failure to ensure a resident who self-administered medications had a self-administration assessment, physician's order, and care plan.
Failure to ensure staff provided privacy during personal care, exposing resident's genitals to roommate.
Failure to maintain effective grievance procedures and inform residents of grievance rights and processes.
Failure to provide restorative range of motion (ROM) services for residents with contractures.
Failure to ensure a safe environment free from accident hazards, including improper gait belt use and unsafe flooring.
Failure to identify and monitor behaviors related to psychotropic medication use and failure to discontinue unnecessary psychotropic medications.
Failure to serve therapeutic diets as ordered by physician for residents.
Failure to maintain a safe, functional, sanitary, and comfortable environment including broken tiles and rusted shelving in shower rooms.
Failure to ensure potable water supply was available and not expired.
Report Facts
Census: 75
Total Capacity: 75
Deficiencies cited: 9
Random audits for gait belt usage: 10
Random audits for gait belt usage: 10
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 17, 2022
Visit Reason
The document serves as a statement of deficiencies and plan of correction for Midlands Living Center LLC, certifying the facility as in compliance effective 11/17/22 based on acceptance of a credible allegation of compliance and plan of correction.
Findings
The facility was found to be in compliance as of 11/17/22 following acceptance of the credible allegation of compliance and plan of correction. No specific deficiencies or severity levels are detailed in the document.
Inspection Report
Annual Inspection
Census: 76
Deficiencies: 3
Date: Oct 6, 2022
Visit Reason
The inspection was conducted as the facility's annual recertification survey and included investigation of complaints #105706-C and #104520-C, as well as a facility-reported incident #107392-I from October 3 to October 6, 2022.
Complaint Details
Complaint #104520-C was not substantiated. Complaint #105706-C was substantiated. Facility-reported incident #107392-I was substantiated.
Findings
The facility was found to have deficiencies related to grievance policies, failure to provide adequate supervision to prevent accidents, and infection control issues including COVID-19 management. Some complaints and incidents were substantiated, and the facility failed to ensure timely call light responses and proper fall prevention measures.
Deficiencies (3)
Failure to establish and implement a grievance policy protecting residents' rights, including timely resolution and documentation of grievances.
Failure to provide adequate supervision and assistance devices to prevent accidents, resulting in a resident rolling down stairs in a wheelchair.
Failure to establish and maintain an infection prevention and control program, including failure to properly isolate COVID-19 positive residents and prevent transmission.
Report Facts
Resident census: 76
Complaint numbers: 3
COVID-19 positive residents: 11
COVID-19 positive residents in 200 Hall: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nursing Assistant (CNA) | Named in call light response grievance findings |
| Staff C | Licensed Practical Nurse (LPN) | Named in grievance form completion and resident care findings |
| Staff B | Certified Medication Aide (CMA) | Named in grievance reporting and call light complaint findings |
| Director of Nursing | DON | Named in grievance and infection control findings |
| Administrator | Named in grievance and fall prevention findings | |
| Staff J | Registered Nurse (RN) | Named in elopement incident findings |
| Staff K | Named in elopement incident findings | |
| Staff A | Assistant Director of Nursing (ADON) | Named in elopement incident findings |
| Staff H | Dietary Manager (DM) | Named in fall incident intervention findings |
| Staff I | Named in fall incident reporting findings |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 3
Date: May 13, 2021
Visit Reason
The recertification survey and investigation of complaint 97102-C was conducted from May 10 to May 13, 2021, to investigate a complaint regarding failure to notify the physician of elevated blood sugar levels for Resident #45.
Complaint Details
Complaint 97102-C was substantiated. The complaint involved failure to notify the physician of elevated blood sugar levels for Resident #45.
Findings
The facility failed to notify the physician of a blood sugar level over 400 for Resident #45 as directed by the physician's order. Additionally, the facility failed to maintain resident rooms in a clean, comfortable, and homelike manner, and failed to meet professional standards in medication administration for Resident #42.
Deficiencies (3)
Failure to notify physician of blood sugar over 400 for Resident #45.
Failure to maintain a safe, clean, comfortable, and homelike environment, including issues with room cleanliness and maintenance.
Failure to meet professional standards in medication administration, including failure to prime insulin pen for Resident #42.
Report Facts
Resident census: 64
Blood sugar level: 413
Blood sugar level: 196
Units of Novolog insulin administered: 20
Rooms reviewed for repairs: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding notification of elevated blood sugar and medication administration policies. |
| Staff B | Registered Nurse (RN) Nurse Manager | Reported contacting hospice and lack of documentation regarding notification of elevated blood sugars. |
| Staff A | Staff | Observed administering insulin and failed to prime insulin pen prior to administration. |
| Staff E | Environmental Services Director | Interviewed regarding room repair and housekeeping practices. |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 1
Date: Feb 2, 2021
Visit Reason
The inspection was conducted as an investigation of multiple complaints and self-reports alleging abuse and mistreatment at the facility.
Complaint Details
The investigation involved complaints #84537-C, #84557-C, #85412-C, #85478-C, #95243-I, #95247-I, and #95322-C. All complaints and self-reports were found not substantiated. The specific allegation involved Staff B holding down Resident #7's arms while yelling at her during cares on 1/20/21. Staff A reported the incident to Staff C, RN, who instructed her to report to the Director of Nursing (DON), but the report to the DON was delayed by two days.
Findings
The facility failed to report an allegation of abuse in a timely manner involving Staff B holding Resident #7's hands down while yelling at her during cares. The complaints and self-reports investigated were all found to be not substantiated.
Deficiencies (1)
Failure to report an allegation of abuse in a timely manner as required by regulation.
Report Facts
Census: 70
Complaint numbers investigated: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Reported the abuse allegation involving Staff B and Resident #7. |
| Staff B | Certified Nursing Assistant (CNA) | Alleged to have held Resident #7's hands down while yelling during cares. |
| Staff C | Registered Nurse (RN) | Received initial report from Staff A and instructed to report to the Director of Nursing. |
| Director of Nursing | DON | Received the abuse report two days after the incident and conducted investigation. |
Inspection Report
Abbreviated Survey
Census: 66
Deficiencies: 0
Date: Dec 1, 2020
Visit Reason
A focused COVID-19 infection control survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Date: Nov 13, 2020
Visit Reason
A focused COVID-19 infection control survey was conducted in conjunction with investigation of complaint #94433-C from 11/10/2020 to 11/13/2020. The complaint was substantiated.
Complaint Details
Complaint #94433-C was investigated from 11/10/2020 to 11/13/2020 and was substantiated.
Findings
The facility failed to notify the Powers of Attorney for three residents who tested positive for COVID-19 in a timely manner. Observations and interviews confirmed delays in notification and communication with residents' representatives regarding positive COVID-19 test results.
Deficiencies (1)
Failure to notify 3 residents' Powers of Attorney of a positive COVID-19 test result in a timely manner.
Report Facts
Resident census: 67
Inspection Report
Abbreviated Survey
Census: 77
Deficiencies: 0
Date: Jun 23, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/23/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report
Apr 24, 2025
Report
Jan 15, 2025
Report
Jan 15, 2025
Report
Sep 30, 2024
Report
Dec 21, 2023
Report
Oct 6, 2022
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