Inspection Report Summary
The most recent inspection on October 15, 2025, found no deficiencies during the recertification visit for the Assisted Living Program for People with Dementia. Earlier inspections showed a pattern of deficiencies primarily related to incident reporting, tenant evaluations, service plan updates, staff training—especially dementia-specific education—and medication administration. Several complaint investigations substantiated issues such as medication errors resulting in tenant harm, incomplete incident documentation, and inadequate policies for managing elopement risks. Enforcement actions included fines ranging from $2500 to $10,000 in earlier years, but no fines or license suspensions were listed in the most recent reports. The facility’s inspection history indicates improvement over time, with recent inspections showing fewer and less frequent deficiencies.
Deficiencies (last 18 years)
Deficiencies (over 18 years)
7.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
61% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
15 residents
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 15
Deficiencies: 0
Date: Oct 15, 2025
Visit Reason
Recertification visit conducted to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the recertification visit for the Assisted Living Program for People with Dementia.
Report Facts
Number of tenants without cognitive impairment: 1
Number of tenants with cognitive impairment: 14
Total census: 15
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 3
Date: Sep 11, 2024
Visit Reason
The inspection was conducted to investigate complaints related to incidents of elopement and wandering behaviors involving tenants at Oak Park Place Memory Care.
Complaint Details
The visit was triggered by complaints identified as Incident #122568-I and Incident #122589-I concerning elopement and wandering incidents involving tenants.
Findings
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.
Deficiencies (3)
Failed to include statements from individuals who witnessed the incident in the incident report for Tenant 1's elopement.
No written procedures regarding appropriate staff response when a tenant's service plan indicates a risk of elopement or wandering behavior.
No written procedures regarding appropriate staff response if a tenant with cognitive disorder or dementia is missing.
Report Facts
Number of tenants with cognitive impairment: 18
Number of tenants without cognitive impairment: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rand Rasmussen | Director of Housing | Named in Plan of Correction response |
| Regional MDS Coordinator | Interviewed regarding policies and incident reports | |
| Regional Nurse | Interviewed and confirmed findings |
Inspection Report
Renewal
Census: 16
Deficiencies: 4
Date: Jan 17, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Program failed to notify the Department within required timeframe when a tenant eloped from the program.
Employment prohibition not met; failure to obtain evaluation from the department of health and human services prior to hire for staff with a history of child abuse.
Failure to maintain complete tenant documentation including routine personal care tasks and safety checks.
Program failed to ensure 3 of 4 staff received 8 hours of dementia-specific training within 30 days of employment.
Report Facts
Total census: 16
Global Deterioration Scale score: 5
Hours of dementia-specific training: 4.5
Hours of dementia-specific training: 5
Hours of dementia-specific training: 6.25
Task checks documented: 84
Task checks documented: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Staff member with history of child abuse; evaluation process not completed prior to hire. | |
| Staff C | Staff member with 4.5 hours dementia-specific training on file; failed to complete 8 hours within 30 days. | |
| Staff G | Staff member with 6.25 hours dementia-specific training on file; failed to complete 8 hours within 30 days. | |
| Director of Housing | Confirmed elopement incident and deficiencies related to notification and training. |
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 1
Date: May 19, 2023
Visit Reason
The inspection was conducted as part of an investigation into Complaint #112178-C regarding regulatory insufficiency related to tenant care and medication administration.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to provide appropriate care and treatment as evidenced by medication administration errors for Tenant #1.
Report Facts
Total census: 19
Medication tablets received: 14
Date of survey completion: May 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Candice Heinkel | Director | Signed the Plan of Correction submitted on behalf of the facility |
Inspection Report
Complaint Investigation
Census: 17
Deficiencies: 9
Date: Mar 14, 2023
Visit Reason
The inspection was conducted in response to complaints #108006-C, #108716-C, and #109298-C regarding regulatory insufficiencies at Oak Park Place Memory Care.
Complaint Details
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.
Findings
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.
Deficiencies (9)
Failure to follow policies and procedures regarding completion of incident reports for tenants and abuse/staff misconduct investigations.
Failure to provide adequate and appropriate care and treatment for a tenant.
Failure to provide policy and procedure addressing provisions related to head injuries.
Failure to complete evaluations as needed with significant change for tenants.
Failure to document nurse's notes by exception for current and discharged tenants.
Failure to ensure service plans were based on evaluations and updated when needs changed.
Failure to ensure service plans were updated and signed within 30 days of occupancy.
Failure to ensure service plans were updated and signed at least annually.
Failure to complete nurse reviews as needed for tenants with significant changes in condition.
Report Facts
Total census: 17
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 16
Number of falls for Tenant #4: 11
Date of survey completion: Mar 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Candice Heinkel | Director of Housing | Named in relation to investigation and plan of correction. |
| Staff C | Reported noticing Tenant #2's bruised eye and involved in investigation. | |
| Staff G | Former staff interviewed regarding Tenant #2's bruising and staff misconduct. | |
| Staff A | Reported bruising on Tenant #3 and staff misconduct. | |
| Staff B | Reported staff smoking marijuana on shift. | |
| Staff H | Terminated for being under the influence at work. | |
| Staff I | Reported to smoke marijuana on shift. | |
| Staff D | Reported for verbal abuse to tenants. | |
| Staff E | Reported Tenant #4 used her pendant. | |
| Staff F | Reported Tenant #4 used her pendant frequently. |
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 3
Date: Aug 10, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to follow the program's policy on Dependent Adult Abuse, including delayed investigation of an alleged abuse incident involving Tenant #1.
Retention of a tenant (Tenant #1) who displayed physical aggression and was dangerous to self and others despite interventions.
Failure to develop service plans based on evaluations for 2 of 3 discharged tenants (Tenants C1 and C3).
Report Facts
Tenant census: 18
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 18
Number of tenants reviewed for abuse policy: 3
Number of discharged tenants reviewed for service plans: 3
Number of discharged tenants with deficient service plans: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Greene | Director of Housing | Signed the Plan of Correction and involved in monitoring compliance |
| Regional Nurse | Conducted investigation into dependent adult abuse and confirmed findings | |
| Interim Director of Housing | Reported delayed investigation of abuse incident and participated in investigation |
Inspection Report
Renewal
Census: 13
Deficiencies: 4
Date: Sep 23, 2021
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for an Assisted Living Program and to investigate Complaint #93153-C.
Complaint Details
No regulatory insufficiencies were cited regarding Complaint 96787-C or Complaint 96470-C. The inspection included investigation of Complaint #93153-C.
Findings
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.
Deficiencies (4)
Failure to ensure 1 of 7 tenants received adequate and appropriate bathing services.
Failure to ensure 4 out of 9 staff completed dependent adult abuse training within 6 months of employment.
Failure to complete evaluations as needed for 2 tenants who experienced significant changes.
Failure to ensure 5 of 9 staff received 8 hours of dementia-specific training including hands-on instruction.
Report Facts
Number of tenants with cognitive disorder: 13
Number of tenants without cognitive disorder: 0
Total census: 13
Staff members reviewed for dependent adult abuse training: 9
Staff members who failed to complete dependent adult abuse training: 4
Staff members reviewed for dementia-specific training: 9
Staff members who failed to complete dementia-specific training including hands-on: 5
Tenants reviewed for evaluation compliance: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Greene | Director of Housing | Signed the Plan of Correction and confirmed findings with Director of Nursing. |
| Staff F | Named in findings related to dependent adult abuse training and dementia-specific training deficiencies. | |
| Staff G | Named in findings related to dependent adult abuse training and dementia-specific training deficiencies. | |
| Staff H | Named in findings related to dependent adult abuse training and dementia-specific training deficiencies. | |
| Staff I | Named in findings related to dependent adult abuse training and dementia-specific training deficiencies. | |
| Director of Housing | Confirmed findings with Director of Nursing on 9/28/21. | |
| Director of Nursing | Confirmed findings with Director of Housing on 9/28/21. |
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 0
Date: Jan 22, 2020
Visit Reason
Investigation into Complaint #87587-C regarding the Assisted Living Program for People with Dementia.
Complaint Details
Investigation into Complaint #87587-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 11
Total Census: 12
Inspection Report
Complaint Investigation
Census: 11
Deficiencies: 6
Date: Nov 7, 2019
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (6)
Program failed to provide a sufficient number of trained staff to fully meet tenants' identified needs.
Program failed to ensure nurse delegations were completed within 30 days of beginning employment for 1 of 3 staff reviewed.
Program failed to complete a criminal history and abuse record background check prior to employment for 1 of 6 staff reviewed.
Program failed to ensure evaluations were completed within 30 days of taking occupancy and as needed with significant change for 1 tenant reviewed.
Program failed to update service plans within 30 days of taking occupancy and as needed with significant change for 1 tenant reviewed.
Program failed to ensure service plans reflected identified needs for 3 tenants reviewed.
Report Facts
Census: 11
Calls during 9-29-19 to 10-6-19: 22
Calls during 10-6-19 to 10-13-19: 7
Calls during 10-13-19 to 10-20-19: 21
Calls during 10-20-19 to 10-27-19: 6
Staff reviewed: 6
Tenants reviewed: 3
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Date: May 28, 2019
Visit Reason
The investigation of Complaint #82894-C was conducted to determine regulatory compliance related to medication storage and administration.
Complaint Details
Investigation of Complaint #82894-C revealed regulatory insufficiency related to medication storage and administration for Tenant #3 receiving insulin.
Findings
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.
Deficiencies (1)
Failure to store program-administered medications in a locked place or container not accessible to persons other than responsible employees, specifically insulin pen stored unsecured in tenant's apartment refrigerator.
Report Facts
Census of Assisted Living Program for People with Dementia: 49
Number of tenants without cognitive disorder in general population: 32
Number of tenants with cognitive disorder in general population: 4
Number of tenants without cognitive disorder in memory care unit: 2
Number of tenants with cognitive disorder in memory care unit: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lessa A Bobak | Regional Nurse | Author of the Plan of Correction letter dated June 13, 2019 |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Date: Dec 3, 2018
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Service plans were not individualized and did not indicate tenant's identified needs and preferences for assistance for 5 tenants reviewed.
Report Facts
Number of tenants without cognitive disorder in general population: 35
Number of tenants with cognitive disorder in general population: 3
Number of tenants without cognitive disorder in memory care unit: 5
Number of tenants with cognitive disorder in memory care unit: 9
Total census of Assisted Living Program for People with Dementia: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cheryl Scheele | Director of Housing | Signed the Plan of Correction letter submitted on behalf of Oak Park Place |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 8
Date: Nov 9, 2017
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (8)
Program failed to follow policy related to dependent adult abuse for 1 of 11 tenants reviewed.
Program failed to provide adequate services including housekeeping, bathing, and diabetic care for multiple tenants.
Program failed to have newly hired registered nurse document a review to ensure staff were sufficiently trained and competent in all tasks.
Program failed to provide medications and treatments as prescribed by a physician for 6 of 11 tenants reviewed.
Program failed to ensure 1 of 1 tenants who displayed aggressive and unmanageable verbal abuse was discharged as required.
Program failed to complete nurses' notes by exception for 5 of 11 tenants reviewed.
Program failed to develop service plans that reflected identified needs for 9 of 11 tenants reviewed.
Program failed to ensure dementia-specific education was completed within 30 days of employment for 6 of 7 staff reviewed.
Report Facts
Number of tenants without cognitive disorder: 39
Number of tenants with cognitive disorder: 22
Total Population of Program at time of on-site: 61
Number of tenants reviewed for dependent adult abuse policy: 11
Number of tenants reviewed for adequate services: 11
Number of tenants reviewed for diabetic care: 6
Number of tenants reviewed for medication administration: 11
Number of medication errors documented: 15
Number of staff reviewed for dementia-specific education: 7
Number of staff who completed dementia-specific education within 30 days: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Grothjan | Director of Housing | Signed Plan of Correction and involved in investigation and corrective actions |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 3
Date: Aug 21, 2017
Visit Reason
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.
Complaint Details
Complaint investigation #68649-C. The complaint was substantiated based on missing evaluations, service plans, and nurse reviews.
Findings
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.
Deficiencies (3)
Failed to evaluate 7 of 28 tenants using a functional, cognitive, and health status tool within 30 days of occupancy or significant change.
Required service plan reviews could not be located for 8 of 28 tenants receiving health or personal care.
90-day nurse reviews could not be located for 8 of 28 tenants receiving personal or health-related care.
Report Facts
Number of tenants without cognitive disorder: 39
Number of tenants with cognitive disorder: 27
Total census: 66
Tenants reviewed: 28
Tenants with missing evaluations: 7
Tenants with missing service plan reviews: 8
Tenants with missing nurse reviews: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lessa Bobak | Interim Director | Signed the Plan of Correction letter dated September 13, 2017 |
| Director of Nursing | Confirmed findings and concerns about missing tenant files and documentation |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 3
Date: May 25, 2017
Visit Reason
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.
Complaint Details
Investigation of Complaint #67393-C identified regulatory insufficiencies related to medication management and tenant care.
Findings
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.
Deficiencies (3)
Program failed to follow policies and procedures regarding narcotic medications affecting multiple tenants, including improper medication orders and administration.
Failure to provide adequate care, treatment, and services for tenants, including nutritional supplements and assistance with dressing.
Staff did not sanitize hands before donning gloves during medication administration and assistance with oral medications.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 35
Number of tenants with cognitive disorder in General Population Program: 2
Total population of General Population Program: 37
Number of tenants without cognitive disorder in Dementia-Specific Program: 1
Number of tenants with cognitive disorder in Dementia-Specific Program: 25
Total population of Dementia-Specific Program: 26
Total census of Assisted Living Program: 63
Weight loss of Tenant #1 in pounds: 21.5
Weight of Tenant #1 in December 2016: 188
Weight of Tenant #1 in March 2017: 179.2
Weight of Tenant #1 in April 2017: 165.4
Weight of Tenant #1 in May 2017: 166.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dara Fishnick | Director of Housing | Signed the Plan of Correction letter dated June 13, 2017 |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
Date: Feb 8, 2017
Visit Reason
Investigation of Complaint #64965-C and Incident #64966-I was completed to assess regulatory insufficiency related to service plans and tenant care.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Program failed to ensure service plans reflected the identified needs of 2 of 3 tenants reviewed.
Report Facts
Census: 60
Tenants without cognitive disorder: 38
Tenants with cognitive disorder: 22
Tenants reviewed: 3
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 1
Date: Dec 14, 2016
Visit Reason
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.
Complaint Details
Complaint #63867-C was investigated and regulatory insufficiency was cited related to hand hygiene and sanitation during medication administration.
Findings
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.
Deficiencies (1)
Failure to follow policies and procedures regarding hand washing and sanitation during medication passes, leading to contamination and improper medication administration.
Report Facts
Number of tenants without cognitive disorder: 39
Number of tenants with cognitive disorder: 18
Total census of Assisted Living Program: 57
Date survey completed: Dec 14, 2016
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 3
Date: Jun 20, 2016
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to follow policy and procedure related to narcotic count resulting in five unaccounted syringes of Lorazepam for Tenant #3.
Failure to administer medications as prescribed by a doctor for Tenant #3, including incorrect dosing and multiple administration errors.
Failure to maintain tenant documents including an incident report for a medication error for Tenant #4.
Report Facts
Census: 57
Number of tenants without cognitive disorder: 38
Number of tenants with cognitive disorder: 19
Unaccounted syringes: 5
Medication administration errors: 35
Syringes filled: 25
Syringes discrepancy: 5
Syringes administered: 46
Syringes destroyed: 6
Syringes remaining: 35
Medication doses missed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dara Fishnick | Director of Housing | Signed Plan of Correction letter and mentioned in interview regarding medication administration and incident reporting |
Inspection Report
Monitoring
Census: 56
Deficiencies: 2
Date: Nov 24, 2015
Visit Reason
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.
Findings
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.
Deficiencies (2)
Service plans were not individualized and did not reflect tenants' identified needs and preferences for assistance for two of five tenant files reviewed.
The program failed to assess and document the health status of each tenant, make recommendations and referrals as appropriate, and monitor progress relating to previous recommendations at least every 90 days and whenever there were changes in the tenant's health status.
Report Facts
Census: 56
Tenant count: 41
Tenant count: 15
Incident reports: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dara Fishnick | Director of Housing | Named in Plan of Correction response letter |
| Rose Boccella | Program Coordinator, Adult Services Bureau | Author of the initial Final Recertification Monitoring Evaluation Report letter |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 0
Date: Jan 22, 2014
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Number of tenants without cognitive disorder: 35
Number of tenants with cognitive disorder: 15
Total census: 50
Date of complaint/incident investigation revisit: Jan 22, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Berkley | RN BS, Program Coordinator | Monitor and author of the report |
| Stephanie Cummins | MA | Monitor during the complaint/incident investigation revisit |
| Lori Steiner | Director of Housing | Named in report as facility contact and involved in training and compliance |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 6
Date: Sep 25, 2013
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (6)
Failure to complete evaluations for three tenants exhibiting changes in condition or required additional interventions.
Failure to update service plans on an ongoing basis and comply with the plan of correction on three occasions.
Service plans not updated to include interventions related to recertification to hospice, increased agitation, yeast infection, and subsequent discharge.
Service plan updates were not supported by evaluations.
Nurse reviews were not consistently completed every 90 days or after significant changes in condition.
Buildings and grounds were not well-maintained, clean, safe, and sanitary.
Report Facts
Civil penalty amount: 2500
Reduced civil penalty amount: 1625
Census: 59
Tenants without cognitive disorder: 46
Tenants with cognitive disorder: 13
Tenant attendance at community meeting: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Mentioned as contact for civil penalty payment and appeal. |
| Jim Friberg | Acting Bureau Chief, Adult Services Bureau | Signed the demand letter. |
| Hal L. Chase | RN BSN MPH, Monitor | Monitor for the complaint/incident investigation. |
| Lori Steiner | Administrator | Administrator of Oak Park Place Assisted Living, named in report. |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 3
Date: Jun 19, 2013
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to update service plans with significant changes and to identify needs and preferences for assistance with certain tenants.
Failure to follow the plan of correction related to service plans for certain tenants.
Medication errors and concerns about medication administration and documentation.
Report Facts
Civil penalty amount: 1500
Reduced civil penalty amount: 975
Census: 54
General Population Program tenants without cognitive disorder: 34
General Population Program tenants with cognitive disorder: 2
Dementia-Specific Program tenants without cognitive disorder: 2
Dementia-Specific Program tenants with cognitive disorder: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Named in relation to appeals, hearings, and contact for questions |
| Hal L. Chase | RN BSN MPH | Monitor for the complaint investigation |
| Stephanie Cummins | MA | Monitor for the complaint investigation |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 5
Date: Mar 12, 2013
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (5)
Failure to comply with criteria for admission and retention of tenants.
Failure to complete functional, cognitive, and health evaluations with significant changes in health status.
Failure to establish interventions related to behaviors, assistance with ADLs, and dementia in service plans.
Medication administration errors including failure to record medications as given.
Failure to update service plans to reflect interventions related to chronic UTIs and confusion.
Report Facts
Civil penalty amount: 1000
Reduced civil penalty amount: 650
Inspection dates: March 12-14, 2013
Census count: 63
Tenants without cognitive disorder: 40
Tenants with cognitive disorder: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Contact person for appeal and civil penalty payment |
| Hal L. Chase | RN BSN MPH | Monitor during complaint/incident investigation |
| James Berkley | RN BS | Monitor during complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 9
Date: Dec 18, 2012
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (9)
A program shall not knowingly admit or retain a tenant who is dangerous to self or others, including those with unmanageable verbal abuse or aggression.
A program’s policies and procedures must meet minimum standards including detailed incident reporting and documentation.
The program did not accurately evaluate Tenant #3’s functional and health status and did not complete functional, cognitive, and health evaluations after significant changes.
The program did not consistently complete incident reports after Tenant #4 had falls or was found on the floor.
Service plans did not establish interventions related to Tenant #1’s combative and aggressive behavior.
Service plans were not updated to include interventions related to falls, wound care, and other significant changes for multiple tenants.
Functional, cognitive, and health evaluations were not completed accurately or timely for several tenants.
The service plan did not establish planned and spontaneous activities based on tenant abilities and interests.
Service plans were not individualized or updated as required by regulations.
Report Facts
Total census: 72
Number of tenants without cognitive disorder: 52
Number of tenants with cognitive disorder: 20
Date of complaint investigation: December 18 & 19, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Signed cover letter regarding acceptance of Plan of Correction |
| Hal L. Chase | RN BSN MPH | Monitor for the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 0
Date: Mar 6, 2012
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Total Population of Program at time of on-site: 73
Medication errors: 23
Medication errors per week: 1
Number of tenants interviewed: 3
Number of tenant files reviewed: 5
Response time to pendant calls: 2.22
Response time to pendant calls: 5.45
Response time to pendant calls: 2.75
Response time to pendant calls: 2.75
Response time to pendant calls: 1.23
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 0
Date: Nov 14, 2011
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 45
Number of tenants with cognitive disorder in General Population Program: 4
Total Population of General Population Program: 49
Number of tenants without cognitive disorder in Dementia-Specific Program: 0
Number of tenants with cognitive disorder in Dementia-Specific Program: 20
Total Population of Dementia-Specific Program: 20
Total census of Assisted Living Program: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cheryl Rogan | Director | Named as facility director in complaint investigation |
| Maribeth Freland | RN | Monitor in complaint/incident investigation |
| Joyce Kix | RN | Monitor in complaint/incident investigation |
Inspection Report
Monitoring
Census: 69
Deficiencies: 0
Date: Oct 5, 2011
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review recertification documents and evaluate the assisted living program at Oak Park Place.
Findings
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.
Report Facts
Number of tenants without cognitive disorder: 47
Number of tenants with cognitive disorder: 22
Total census of Assisted Living Program: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cheryl Rogan | Director of Housing | Named as recipient and director of the facility |
| Stephanie Cummins | MA | Monitor for the evaluation |
| Margaret Kaltefleiter | RN MS | Monitor for the evaluation |
| Jim Berkley | Program Coordinator | Author of the cover letter for the report |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
Date: Apr 19, 2011
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
None noted related to the incident.
Report Facts
Civil penalty amount: 2000
Days to submit Plan of Correction: 10
Days for appeal: 30
Total census: 60
General Population Program tenants without cognitive disorder: 41
General Population Program tenants with cognitive disorder: 2
General Population Program total: 43
Dementia Specific Program total: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | MA | Monitor for the incident investigation. |
| Margaret Kaltefleiter | RN MS | Monitor for the incident investigation. |
| Jim Berkley | Program Coordinator mentioned in relation to civil penalty and appeals. | |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter and conclusion. |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 0
Date: Mar 22, 2011
Visit Reason
The inspection was conducted as a final incident investigation following a reported tenant fall incident at Oak Park Place on March 22, 2011.
Complaint Details
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.
Findings
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.
Report Facts
Current number of tenants without cognitive disorder: 42
Current number of tenants with cognitive disorder: 2
Total Population of General Population Program: 44
Total Population of Dementia Specific Program: 17
Total Census of Assisted Living Program: 61
Incident Report date: Mar 4, 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Signed cover letter for the report |
| Stephanie Cummins | MA | Monitor for the incident investigation |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 0
Date: Mar 2, 2011
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Current number of tenants without cognitive disorder: 40
Current number of tenants with cognitive disorder: 3
Total Population of GPP: 43
Total Population of Dementia Specific Program (DSP): 17
Total Census of ALP: 60
Tenant age: 91
Tenant age: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Signed the cover letter for the report |
| Stephanie Cummins | MA | Monitor for the investigation |
| Margaret Kaltefleiter | RN | Monitor for the investigation |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 8
Date: Aug 9, 2010
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (8)
Failure to evaluate each tenant's functional, cognitive and health status within 30 days of occupancy and annually thereafter.
Service plans did not address interventions for urinary tract infection or pain and lacked specifics regarding hospice and other service providers.
Multiple medication errors and failure to complete narcotic counts according to policy.
Failure to follow physician's orders and complete nurse reviews for changes in health condition.
Lack of registered nurse on staff to answer questions, though corporate RN was available by phone.
Failure to provide access to a personal emergency response system for tenants with cognitive impairment.
Failure to complete and document dementia or dependent adult abuse training for staff.
Failure to notify director or designee within 24 hours when a tenant elopes from the program.
Report Facts
Civil penalty amount: 2500
Reduced civil penalty amount: 1625
Census: 55
General Population Program tenants without cognitive disorder: 36
General Population Program tenants with cognitive disorder: 1
Dementia Specific Program tenants: 18
Complaint investigation dates: 3
Longest average response time to pendant calls: 3.2
Cognitive evaluation score for Tenant #2: 24
Cognitive evaluation score for Tenant #4: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jackie Scott | Housing Director | Named as contact for Oak Park Place Assisted Living Program |
| Hal Chase | RN BSN MPH | Monitor for the complaint investigation |
| Joyce Kix | RN | Monitor for the complaint investigation |
| Tamara Halvorson | Certification Coordinator | Contact for appeal and civil penalty payment |
| Staff #5 | Acknowledged medication administration policy and narcotic count procedures | |
| Staff #6 | Licensed Practical Nurse | Reported working during investigation period |
| Staff #9 | Discovered tenant on floor and reported alarm not sounding | |
| Staff #4 | Reported tenant's alarm sounded all the time but service plan lacked specifics |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: Apr 14, 2010
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Medications were not documented as given or not given for multiple tenants on various dates.
Report Facts
Current number of tenants without cognitive disorder: 32
Current number of tenants with cognitive disorder: 4
Total Population of General Population Program: 36
Total Population of Dementia Specific Program: 19
Total Census of Assisted Living Program: 55
Medication administration calls reviewed: 486
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chris Nothaft | Certification Coordinator – Eastern Iowa | Signed letter accepting Plan of Correction |
| Hal L. Chase | RN BSN MPH | Monitor for complaint investigation |
| Stephanie Cummins | MA | Monitor for complaint investigation |
| Jackie Scott | Director of Housing | Facility Director named in report |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 7
Date: Nov 9, 2009
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (7)
The program did not evaluate each tenant’s functional, cognitive and health status as needed to determine continued eligibility and modifications to services.
The program did not update service plans as needed with changes in health status.
The program did not individualize tenant service plans to include identified needs and requests for assistance.
The program did not complete nurse reviews as needed for tenants receiving physical therapy or with other health needs.
The program did not assess and document health status, make recommendations and referrals, or monitor progress on previous recommendations.
The program did not ensure health care professionals’ orders for tenants receiving professional-directed care were current.
The program did not maintain documentation in accordance with Iowa Code and administrative rules, including medication administration records and clinical records.
Report Facts
Current number of tenants without cognitive disorder: 37
Current number of tenants with cognitive disorder: 4
Total Population of General Population Program (GPP): 41
Total Population of Dementia Specific Program (DSP): 12
Total Census of Assisted Living Program (ALP): 53
Dates of investigation: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jackie Scott | Director of Housing | Named as recipient of report and involved in certification and recertification process |
| Stephanie Cummins | Monitor | Conducted complaint investigation |
| Joyce Kix | RN, Monitor | Conducted complaint investigation |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 3
Date: Apr 8, 2009
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations regarding tenant care and staff conduct at Oak Park Place Assisted Living.
Complaint Details
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.
Findings
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.
Deficiencies (3)
The program did not consistently provide individualized service plans reflecting tenant needs and requests.
The program did not consistently provide sufficient trained staff available at all times to fully meet tenants' identified needs.
The program did not consistently complete employee record checks prior to hire.
Report Facts
Civil penalty amount: 5500
Current number of tenants without cognitive disorder: 32
Current number of tenants with cognitive disorder: 2
Total Population of General Population Program: 34
Total Population of Dementia Specific Program: 12
Total Census of Assisted Living Program: 46
Days to come into compliance: 75
Fine amount from March 31, 2008 recertification: 2500
Fine amount from July 24, 2008 complaint and recertification: 4000
Fine amount from September 25 & 29, 2008 complaint visit: 10000
Fine amount from January 5 & 6, 2009 complaint visits: 2000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal Chase | RN BSN MPH | Monitor for the complaint investigation. |
| Stephanie Cummins | MA | Monitor for the complaint investigation. |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed report and communicated sanctions. |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 11
Date: Jan 5, 2009
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (11)
Regulatory insufficiency related to not consistently completing tenant evaluations.
Regulatory insufficiency related to not consistently updating service plans.
Regulatory insufficiency related to inconsistent following of physician orders for blood sugar monitoring.
Regulatory insufficiency related to administration of medications not by licensed nurse or authorized agent.
Regulatory insufficiency related to not consistently administering medications appropriately.
Regulatory insufficiency related to not consistently administering medications by licensed nurse or authorized agent.
Regulatory insufficiency related to staff not consistently providing sufficient trained staff to meet tenant needs.
Regulatory insufficiency related to not consistently ensuring all staff can implement accident, fire safety, and emergency procedures.
Regulatory insufficiency related to falsifying staff training records regarding dependent adult abuse.
Regulatory insufficiency related to not reporting suspected exploitation of a dependent adult.
Regulatory insufficiency related to not consistently providing buildings and grounds that are well maintained, clean, safe, and sanitary.
Report Facts
Current number of tenants without cognitive disorder: 31
Current number of tenants with cognitive disorder: 3
Total Population of General Population Program: 34
Total Population of Dementia Specific Program: 13
Total Census of Assisted Living Program: 47
Fine amount: 2000
Fine amount: 2500
Fine amount: 4000
Fine amount: 10000
Number of incidents of tenant's blood sugars outside parameters: 14
Date of investigation: Jan 5, 2009
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal Chase | RN BSN MPH | Monitor for the complaint investigation |
| Stephanie Cummins | MA | Monitor for the complaint investigation |
| Ann Martin | RN, Bureau Chief Adult Services Bureau | Signed report and involved in monitoring |
| Toni Carruthers | Acting Administrator | Administrator of Oak Park Place Assisted Living |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 7
Date: Sep 25, 2008
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (7)
Failure to consistently evaluate each tenant’s functional, cognitive and health status as needed.
Failure to update service plans as needed and develop service plans based on evaluations.
Medication administration errors including failure to administer prescribed medications and inconsistent documentation.
Inadequate staffing to meet tenant needs and respond to emergencies.
Staff did not receive required dementia-specific education and dependent adult abuse training.
Falsification of dependent adult abuse training forms by staff.
Failure to fully implement the Plan of Correction.
Report Facts
Civil penalty amount: 10000
Complaint intake numbers: 3
Tenant census: 42
Tenant census: 14
Total census: 56
Fines from prior visits: 2500
Fines from prior visits: 4000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tim Hendricks | Director of Housing Operations | Named as recipient of the report and involved in statements regarding falsification of dependent adult abuse training forms. |
| Ann Martin | Bureau Chief, Adult Services Bureau | Author of the report and signatory. |
| Hal Chase | RN BSN, MPH | Monitor for the complaint investigation. |
| Stephanie Cummins | SW MA | Monitor for the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 5
Date: Jul 24, 2008
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (5)
Failure to evaluate tenants' functional, cognitive, and health status as needed to determine continued eligibility and service modifications.
Program did not consistently exclude tenants requiring routine two-person assistance with transfer, ambulation, or evacuation.
Numerous medication errors and failure to consistently administer medications according to nursing standards.
Staff not consistently trained or maintaining documentation for Dependent Adult Abuse (DAA) requirements.
Plan of Correction was not fully implemented as required.
Report Facts
Census - General Population Program (GPP): 46
Census - Dementia Specific Program (DSP): 14
Civil penalty amount: 4000
Staff training attendance: 14
Program staff count: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the complaint investigation. |
| Ann Martin | Bureau Chief, Adult Services Bureau | Author of the sanction and penalty letter. |
| Tim Hendricks | Director of Housing Operations | Facility director named in the report. |
Inspection Report
Monitoring
Census: 58
Deficiencies: 6
Date: Mar 31, 2008
Visit Reason
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.
Findings
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.
Deficiencies (6)
Did not consistently evaluate each tenant's functional, cognitive, and health status within 30 days of occupancy and as needed.
Did not consistently update service plans when tenants needed personal or health-related care.
Medication errors in administration and documentation for multiple tenants.
Did not consistently complete nurse reviews and document health status changes timely.
Did not consistently provide sufficient trained staff to meet tenants' needs.
Did not fully implement the Plan of Correction submitted.
Report Facts
Current number of tenants without cognitive disorder: 44
Current number of tenants with cognitive disorder: 14
Total Population: 58
Civil penalty amount: 2500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | SW MA | Monitor for the inspection visit |
| Lincoln Newsom | RN | Monitor for the inspection visit |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed letter regarding acceptance of Plan of Correction and civil penalty |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 2
Date: Feb 27, 2008
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
The program did not consistently provide sufficient trained staff at all times to fully meet the tenants’ identified needs.
The program did not establish and maintain a safe and homelike environment for individuals who require assistance to live independently but do not require continuous health-related care.
Report Facts
Current number of tenants without cognitive disorder in General Population Program: 40
Current number of tenants with cognitive disorder in General Population Program: 2
Total Population in General Population Program: 42
Current number of tenants in Dementia Specific Program: 14
Current number of tenants without cognitive disorder in Dementia Specific Program: 2
Total Population in Dementia Specific Program: 16
Date of Staff #1 termination: Jan 24, 2008
Date of Staff #1 dependent adult abuse training: Apr 19, 2006
Hours of dementia training completed by Staff #1: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tim Hendricks | Director of Housing Operations | Provided investigation summary and information about notification of families |
| Stephanie Cummins | SW MA | Monitor of the complaint investigation |
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