Inspection Reports for Oak Park Place Dubuque

Recertification visit conducted to determine compliance with certification of an Assisted Living Program for People with Dementia.

No regulatory insufficiencies were cited during the recertification visit for the Assisted Living Program for People with Dementia.

The inspection was conducted to investigate complaints related to incidents of elopement and wandering behaviors involving tenants at Oak Park Place Memory Care.

The program failed to follow its policy on incident reporting by not including witness statements for an elopement incident. Additionally, the program lacked written procedures addressing appropriate staff responses to tenants at risk of elopement or wandering, and no specific policy existed for staff response when a tenant with cognitive disorder or dementia was missing.

The visit was triggered by complaints identified as Incident #122568-I and Incident #122589-I concerning elopement and wandering incidents involving tenants.

The inspection was conducted to investigate Complaint #115152-C and to recertify compliance with certification requirements for an Assisted Living Program for People with Dementia.

The inspection found regulatory insufficiencies related to program notification failures, incomplete staff evaluations, incomplete tenant documentation, and inadequate dementia-specific training for staff. Specific deficiencies included failure to notify the department of tenant elopement, failure to complete required background checks, incomplete documentation of routine personal care tasks, and insufficient dementia-specific training hours for staff.

The complaint investigation involved review of Tenant #3's elopement incident occurring on 12/28/23. The program failed to notify the Department within 24 hours as required. The complaint was substantiated based on these findings.

The inspection was conducted as part of an investigation into Complaint #112178-C regarding regulatory insufficiency related to tenant care and medication administration.

The program failed to provide appropriate services to one tenant by incorrectly updating medication administration records, leading to a medication error where Tenant #1 was given Risperdal instead of Ropinirole. This error resulted in the tenant experiencing neurological symptoms and hospitalization.

The visit was triggered by Complaint #112178-C. The complaint was substantiated as the program failed to provide appropriate services to Tenant #1, resulting in a medication error and adverse health effects.

The inspection was conducted in response to complaints #108006-C, #108716-C, and #109298-C regarding regulatory insufficiencies at Oak Park Place Memory Care.

The program failed to follow policies and procedures related to incident reporting, abuse/staff misconduct investigations, and staff drug/alcohol use. Additionally, failures were noted in providing adequate care, completing evaluations and nurse reviews, documenting nurse's notes, and updating service plans as required.

Complaints #108006-C, #108716-C, and #109298-C were investigated. The investigation found failures in incident reporting, abuse investigations, staff substance use, and care provision.

The inspection was conducted as a complaint investigation into multiple complaints (#100892-C, #100876-C, #100173-C, and #105135-C) regarding regulatory compliance at Oak Park Place Memory Care.

No regulatory insufficiencies were found for complaints #100892-C and #100876-C. However, deficiencies were cited related to failure to follow dependent adult abuse policies, retention of a tenant with aggressive behavior, and failure to develop service plans based on evaluations for discharged tenants.

The investigation was triggered by complaints #100892-C, #100876-C, #100173-C, and #105135-C. No deficiencies were found for complaints #100892-C and #100876-C. Deficiencies were cited related to complaints #100173-C and #105135-C.

The inspection was conducted as a recertification visit to determine compliance with certification for an Assisted Living Program and to investigate Complaint #93153-C.

The inspection found regulatory insufficiencies related to tenant rights, staffing, evaluation of tenants, and dementia-specific education for personnel. Specific deficiencies included failure to ensure adequate bathing services, incomplete dependent adult abuse training for staff, incomplete evaluations for tenants with significant changes, and insufficient dementia-specific training with hands-on components for staff.

No regulatory insufficiencies were cited regarding Complaint 96787-C or Complaint 96470-C. The inspection included investigation of Complaint #93153-C.

Investigation into Complaint #87587-C regarding the Assisted Living Program for People with Dementia.

No regulatory insufficiencies were cited during the complaint investigation.

Investigation into Complaint #87587-C found no regulatory insufficiencies.

The inspection was conducted to investigate Complaint #85988-C and to conduct a recertification visit to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.

The inspection found multiple regulatory insufficiencies related to staffing, nurse delegation training, record checks, tenant evaluations, and service plans. Specific issues included insufficient trained staff to meet tenant needs, failure to complete nurse delegations within 30 days, incomplete criminal background checks prior to employment, failure to complete tenant evaluations within 30 days of occupancy, and failure to update service plans based on significant changes.

The visit was triggered by Complaint #85988-C and included a recertification visit for compliance with certification for a Dedicated Dementia Specific Assisted Living Program.

The investigation of Complaint #82894-C was conducted to determine regulatory compliance related to medication storage and administration.

The program failed to store program-administered medications in a secured location for one tenant receiving insulin. Staff assisted the tenant with insulin administration, but the insulin pen was stored in a non-secured location (refrigerator in tenant's apartment), contrary to the program's medication policy.

Investigation of Complaint #82894-C revealed regulatory insufficiency related to medication storage and administration for Tenant #3 receiving insulin.

The inspection was conducted as a complaint investigation related to regulatory insufficiency cited during the investigation of Complaint #78742-C at Oak Park Place Assisted Living.

The program failed to ensure tenant service plans reflected their needs, specifically for 5 tenants reviewed. Deficiencies included lack of wound care instructions, medication refusal not addressed in service plans, and missing interventions for showering and medication compliance.

The complaint investigation found a regulatory insufficiency related to service plans not meeting requirements for tenants with cognitive disorders and other care needs. No regulatory insufficiencies were cited during a prior investigation of Incident #79876-I.

A recertification visit was conducted to determine compliance with certification for a dedicated dementia-specific assisted living program. Additionally, an investigation of Complaint #70617-C and Incident #70638-I was completed.

The program failed to follow policies related to dependent adult abuse reporting and investigation, failed to provide adequate services including housekeeping, bathing, and diabetic care, and failed to ensure proper medication administration and staff training. Several tenants had documented issues with care and service plans, and there were multiple medication errors and incidents of aggressive behavior.

Investigation of Complaint #70617-C and Incident #70638-I related to allegations of inappropriate touching of Tenant #4 was completed. The investigation concluded no inappropriate touching occurred; the tenant's confusion and medical conditions contributed to the allegations. The complaint was not substantiated.

The inspection was conducted as a complaint investigation (#68649-C) to evaluate regulatory compliance related to tenant evaluations, service plans, and nurse reviews at Oak Park Place Assisted Living.

The facility failed to ensure timely evaluations of tenants' functional, cognitive, and health status within 30 days of occupancy or significant change for 7 of 28 tenants reviewed. Required service plan reviews were missing for 8 of 28 tenants receiving health or personal care. Additionally, 90-day nurse reviews were not located for 8 of 28 tenants reviewed. The Director of Nursing confirmed concerns about missing documentation, which had been removed by a former employee.

Complaint investigation #68649-C. The complaint was substantiated based on missing evaluations, service plans, and nurse reviews.

The inspection was conducted as an investigation of Complaint #67393-C to identify regulatory insufficiencies related to the Assisted Living Program at Oak Park Place.

The program failed to follow policies and procedures regarding narcotic medications, including improper medication orders, administration errors, and inaccurate narcotic counts. Additionally, the program failed to provide adequate care and services for tenants, including nutritional supplements and assistance with dressing. Hand hygiene and glove use during medication administration were also deficient.

Investigation of Complaint #67393-C identified regulatory insufficiencies related to medication management and tenant care.

Investigation of Complaint #64965-C and Incident #64966-I was completed to assess regulatory insufficiency related to service plans and tenant care.

The investigation found that the program failed to ensure service plans reflected the identified needs of tenants, specifically tenants #1 and #3. Tenant #1's service plan lacked direction for staff assistance during toileting, and Tenant #3 exhibited multiple behavioral issues not adequately addressed in the service plan.

Complaint #64965-C and Incident #64966-I were investigated. The complaint was related to service plans and tenant care. Specific tenant incidents and behaviors were documented, including safety concerns and behavioral outbursts.

The inspection was conducted as a complaint investigation related to regulatory insufficiencies cited during the investigation of Complaint #63867-C at Oak Park Place Assisted Living.

The investigation found that staff failed to follow proper hand washing and sanitation procedures during medication passes, including contamination of medication and improper glove use. The Director of Health Care Services confirmed expectations for hand hygiene and provided policies and training to address these issues.

Complaint #63867-C was investigated and regulatory insufficiency was cited related to hand hygiene and sanitation during medication administration.

The inspection was conducted as a complaint/incident investigation following allegations related to tenant rights and regulatory insufficiencies concerning program policies, procedures, medications, and tenant documents at Oak Park Place.

The investigation found no regulatory insufficiencies related to tenant rights allegations, which were unsubstantiated. However, regulatory insufficiencies were identified related to program policies and procedures, medication administration, and tenant documents, requiring a Plan of Correction.

The complaint investigation involved allegations of tenant rights which were unsubstantiated. Regulatory insufficiencies were identified related to Incident #60369-I involving medication administration and tenant documents.

The visit was a Final Recertification Monitoring Evaluation conducted by the Department of Inspections and Appeals (DIA) to determine compliance with certification for an Assisted Living Program at Oak Park Place.

The report identified regulatory insufficiencies in the areas of Service Plans and Nurse Review. Specifically, service plans were not individualized or did not reflect tenants' identified needs, and nurse reviews were not completed as required every 90 days or when health status changed.

The inspection was a Final Complaint/Incident Investigation Revisit and Recertification Monitoring Evaluation Revisit conducted on January 22 & 23, 2014, to evaluate compliance following a prior complaint investigation and recertification.

No regulatory insufficiencies were identified during the revisit. The program was found to be in full compliance with administrative rules, with no deficiencies noted in evaluation, service plans, nurse review, or structural requirements. Previous sanctions were lifted and the program was issued a standard certification effective January 24, 2014.

The complaint investigation revisit addressed prior regulatory insufficiencies related to tenant rights, evaluations, service plans, nurse review, and structural requirements identified during the September 2013 recertification and complaint investigation. The revisit found no regulatory insufficiencies and the plan of correction was deemed effective.

The inspection was conducted as a Final Complaint/Incident Revisit Investigation & Recertification Report following a complaint intake #41696-CR3, assessing regulatory insufficiencies at Oak Park Place Assisted Living.

The report found repeated regulatory insufficiencies in evaluations, service plans, nurse review, structural requirements, and compliance with the plan of correction. The facility failed to complete evaluations and update service plans for certain tenants and had ongoing issues with housekeeping and staff responsiveness.

Complaint/Incident Intake #41696-CR3. The complaint investigation was substantiated with findings of regulatory insufficiencies in evaluations, service plans, nurse review, structural requirements, and compliance with the plan of correction.

The inspection was conducted as a complaint and complaint revisit investigation following multiple complaint intakes regarding Oak Park Place Assisted Living. The investigation focused on regulatory insufficiencies related to service plans and noncompliance with the plan of correction.

The report found repeated regulatory insufficiencies in service plans and failure to comply with the plan of correction. Several complaints were investigated including tenant rights, admission and retention criteria, evaluations, service plans, medications, staffing, structural requirements, and compliance with the plan of correction. No regulatory insufficiencies were noted in many areas, but some deficiencies related to service plans and medication administration were identified.

The complaint investigation was triggered by multiple complaint intakes alleging issues such as breach of tenant confidentiality, abuse, failure to meet admission and retention criteria, failure to complete evaluations, falls, untreated UTIs, failure to weigh tenants weekly, failure to update service plans, medication errors, inadequate staffing, illegal drug use by staff, non-direct care staff providing care without training, and structural hazards. Some allegations were substantiated with monitoring observations; others had no regulatory insufficiencies noted.

The inspection was conducted as a complaint/incident investigation following complaints regarding regulatory insufficiencies in criteria for admission and retention, evaluation, service plan, medications, and compliance with plan of correction at Oak Park Place Assisted Living.

The report found multiple regulatory insufficiencies related to admission and retention criteria, evaluation, service plans, medication administration, and compliance with the plan of correction. Several tenants did not meet admission or retention criteria, service plans were not individualized or updated appropriately, and medication errors were documented. A civil penalty of $1,000 was assessed.

The complaint investigation was initiated due to allegations that a tenant exceeded criteria for admission and retention, unsafe use of passenger vehicle, and failure to complete incident reports. The investigation substantiated regulatory insufficiencies in admission and retention, evaluation, service plans, medications, and compliance with plan of correction.

The inspection was conducted as a Final Complaint/Incident Investigation at Oak Park Place Assisted Living in response to allegations regarding staffing adequacy and tenant care.

The investigation reviewed tenant files and staff interviews, finding no staffing insufficiencies but identifying regulatory insufficiencies related to service plans, incident reporting, and evaluations of tenants, particularly concerning falls, cognitive decline, and care interventions.

The complaint alleged insufficient staffing when tenants needed to be transferred and that some tenants required too much care to reside in an assisted living program. The investigation found no staffing insufficiencies but identified multiple regulatory insufficiencies related to tenant care plans, evaluations, and incident reporting.

The inspection was conducted as a complaint/incident investigation following allegations of preferential treatment of tenants, medication errors, and unanswered call lights at Oak Park Place, Dubuque, IA.

The investigation found no regulatory insufficiencies related to tenant rights, medications, or staffing. Tenants reported receiving requested services and appropriate medication administration, and staff response times to pendants were within acceptable limits.

The complaint alleged preferential treatment of certain tenants, medication errors, and unanswered call lights. Investigators interviewed tenants and staff, reviewed medication administration records, and observed medication passes. No regulatory insufficiencies were identified in any of the complaint areas.

The inspection was conducted as a final complaint/incident investigation following allegations that four department directors were drinking alcoholic beverages during a meeting held at the program.

The investigation found that four department directors did consume alcoholic beverages during a meeting on 11-4-11, but no tenants were affected and no regulatory insufficiencies were identified.

The complaint alleged that four department directors were drinking alcoholic beverages during a meeting. The allegation was confirmed by staff, but no regulatory insufficiencies were found and personnel issues are not governed by the Department of Inspections and Appeals.

The visit was a Final Recertification Monitoring Evaluation conducted to review recertification documents and evaluate the assisted living program at Oak Park Place.

No regulatory insufficiencies were found during this evaluation. The program was accepted, and the State Fire Marshal's inspection and Facility Engineer's approval of evacuation plans were received. Tenant satisfaction was generally positive with some requests for improvements.

The visit was conducted as a Final Incident Investigation Report following a complaint related to a tenant fall resulting in a fractured hip at Oak Park Place, an assisted living program in Dubuque, IA.

The investigation found no regulatory insufficiencies related to the incident. The tenant fell, sustained a fractured right hip, was hospitalized, and subsequently died. The program reported the fall with significant injury appropriately and staff responded adequately to the incident.

The complaint involved a tenant who fell after being found resting against a wall, resulting in a fractured right hip. Staff and hospice responded appropriately. The tenant was transferred to a hospital and later to a nursing facility, where the tenant died. The fall was reported appropriately with significant injury.

The inspection was conducted as a final incident investigation following a reported tenant fall incident at Oak Park Place on March 22, 2011.

The investigation found that a tenant sustained a left distal femur fracture after a fall in the bathroom. Staff responded promptly, emergency services were called, and the tenant was transferred to a skilled nursing facility. No regulatory insufficiencies were identified.

The complaint involved a tenant who fell while attempting to go to the bathroom independently. The tenant's spouse hit the pendant for assistance, and staff responded. The tenant sustained a femur fracture. The investigation included interviews, review of incident reports, and pendant system history. No regulatory insufficiencies were substantiated.

The visit was conducted as a final incident and complaint investigation at Oak Park Place related to allegations of inappropriate nurse follow-up regarding a tenant's hospitalization and surgery, and a staff incident involving tenant interactions.

No regulatory insufficiencies were identified during the investigation. Observations found that nursing services and oversight were adequate, staff were respectful, and allegations of staff under the influence and tenant mistreatment were unfounded or unsubstantiated.

Complaint Allegation #32182-C involved concerns about nurse follow-up for a tenant with pain and surgery, and allegations of staff under the influence. Incident Allegation #33088-I involved a staff incident where a tenant slapped staff and another tenant. Both complaints were investigated with no regulatory insufficiencies found; the staff under influence allegation was unfounded and the tenant incident was found unsubstantiated due to hearsay.

A complaint and incident investigation on-site visit was conducted at Oak Park Place on August 9, 10 and 11, 2010, triggered by complaints regarding tenant evaluation, service plans, medications, nurse review, staffing, and other issues.

The investigation found multiple regulatory insufficiencies including inadequate evaluation of tenants, incomplete service plans, medication errors, lack of nurse review, staffing concerns, and failure to properly document and respond to incidents. A $2500 civil penalty was assessed.

Complaint intake numbers 29947-C, 29948-C, and 29727-I involved allegations of medication errors, lack of nurse review, staffing issues, and incidents including a tenant fall resulting in a fractured hip. The complaints were substantiated with multiple regulatory insufficiencies identified.

A complaint investigation was conducted at Oak Park Place Assisted Living on April 14 and 15, 2010, in response to multiple allegations including medication administration issues, locked doors restricting access, a tenant fall with injury, staff sleeping on duty, and dietary staff access to refrigerators.

The investigation found no substantiated regulatory insufficiencies related to tenant care, staffing, or dietary access. Medication administration documentation had multiple omissions but was not deemed a regulatory insufficiency. Staff and tenant interviews indicated adequate staffing and response to calls. The front door locked at 8:00 p.m. with procedures in place for access. No staff were found sleeping on duty during the investigation period.

The complaint investigation was triggered by allegations of a tenant not receiving antibiotics timely, locked program doors restricting visitor access, a tenant fall resulting in a fractured hip, staff sleeping while on duty, and dietary staff restricting access to refrigerators. The investigation found no substantiated regulatory insufficiencies.

An on-site complaint investigation and recertification visit was conducted at Oak Park Place on November 9 & 10, 2009, in response to complaints alleging inadequate tenant assessments, improper tenant transfers, staffing issues, medication administration concerns, and confidentiality breaches.

The investigation found multiple regulatory insufficiencies including failure to evaluate tenants' functional, cognitive, and health status adequately, incomplete service plans, lack of nurse reviews, and documentation deficiencies. However, no substantiated regulatory insufficiencies were noted regarding staffing levels, medication administration training, or confidentiality breaches.

Complaint allegations included tenants not being assessed appropriately by nursing staff, tenants being two-person transfers, aides not properly trained regarding medication administration, excessive staff phone use, improper staff on each shift to assess tenants, lack of RN on duty, and breach of tenant confidentiality. The investigation found no substantiated regulatory insufficiencies related to staffing levels, medication administration training, or confidentiality breaches.

The inspection was conducted as a complaint investigation triggered by allegations regarding tenant care and staff conduct at Oak Park Place Assisted Living.

The investigation found multiple regulatory insufficiencies including failure to provide individualized service plans, inadequate staffing to meet tenant needs, incomplete employee record checks, and issues related to tenant toileting and medication administration. A conditional certificate remains in effect with sanctions and a civil penalty assessed.

Complaint allegations included tenant altercations, inadequate toileting assistance, staff requesting pain medication improperly, and hiring a caregiver without complete background checks. The complaint was substantiated with findings of regulatory insufficiencies.

The inspection was conducted as a complaint investigation and complaint revisit at Oak Park Place Assisted Living in Dubuque, IA, triggered by multiple complaint intakes regarding regulatory insufficiencies in staffing, structural requirements, and other areas.

The investigation found multiple regulatory insufficiencies related to tenant evaluations, service plans, medication administration, staffing, dementia-specific education, structural requirements, and other program noncompliance issues. The program was under a conditional certificate with sanctions including fines and training requirements.

The complaint investigation was substantiated with findings of regulatory insufficiencies in multiple areas including staffing, medication administration, tenant evaluations, service plans, training, and structural requirements. The program was under conditional operation with sanctions and fines.

The inspection was a complaint investigation conducted at Oak Park Place on September 25 and 29, 2008, triggered by multiple complaint intakes (#19524-C, #18205-C, #19334-C) regarding regulatory insufficiencies in tenant evaluation, service plans, medications, staffing, dementia-specific education, and other areas.

The investigation found multiple regulatory insufficiencies including failure to consistently evaluate tenants' functional and cognitive status, incomplete service plans, medication administration errors, inadequate staffing and training, and issues with dementia-specific education and dependent adult abuse training. The program was under a conditional certificate and assessed a $10,000 civil penalty.

The complaint investigation was substantiated with findings of regulatory insufficiencies in tenant evaluation, service plans, medications, staffing, dementia-specific education, and other areas. The program was under a conditional certificate and assessed a $10,000 civil penalty.

The visit was conducted as a Final Complaint, Complaint Revisit, and 2nd Recertification Revisit at Oak Park Place Assisted Living in response to complaints and regulatory monitoring related to tenant care, staffing, and compliance with assisted living program regulations.

The program was found to have multiple regulatory insufficiencies including failure to evaluate tenants' functional and cognitive status, inconsistent exclusion of tenants requiring higher care levels, medication administration errors, inadequate staff training on Dependent Adult Abuse (DAA), and incomplete implementation of the Plan of Correction. A conditional certificate was extended and a $4,000 civil penalty was assessed.

The complaint investigation included allegations that tenants were transferred more than 50% of the time by two persons, Tenant #8 was drinking and falling several times daily, memory care unit was not properly staffed, staff were improperly drawing insulin, and concerns about MRSA care and training. The complaints were substantiated with findings of regulatory insufficiencies.

The visit was an on-site monitoring evaluation revisit conducted to assess regulatory insufficiencies related to tenant evaluations, service plans, medications, nurse review, and other areas in the assisted living program at Oak Park Place.

The program had multiple regulatory insufficiencies including inconsistent evaluation of tenants' functional and cognitive status, incomplete service plans, medication administration errors, incomplete nurse reviews, and insufficient staffing. The Plan of Correction was accepted but not fully implemented at the time of revisit.

A complaint investigation on-site visit was conducted at Oak Park Place to investigate allegations of staff abuse and related concerns reported by the program.

The investigation found that Staff #1 struck Tenant #1 and verbally abused other tenants, leading to Staff #1's termination. The program did not consistently provide sufficient trained staff to meet tenants' needs and failed to maintain a safe and homelike environment.

The complaint involved allegations that Staff #1 struck Tenant #1 on the tenant’s right arm and verbally abused other tenants in the dementia unit. Staff #1 was terminated following the investigation. The Department of Human Services was called but did not investigate. Families of the involved tenants were notified.