Inspection Report Summary
The most recent inspection on October 22, 2025 found the facility to be in substantial compliance with no deficiencies noted. Earlier inspections showed a mix of results, including a medication administration deficiency in August 2024 and multiple care planning and safety issues identified in April 2024. Prior complaint investigations were mostly unsubstantiated, with one partially substantiated complaint and a substantiated incident related to skin impairment and fall investigations in 2021. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record suggests improvement over time, with recent inspections showing compliance following earlier citations.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
1.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
66% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
57 residents
Based on a August 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 22, 2025
Visit Reason
A complaint investigation for complaint #2626534-C was conducted from October 20, 2025 to October 22, 2025.
Complaint Details
Complaint #2626534-C was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 18, 2025
Visit Reason
An annual recertification survey and investigation of a facility reported incident #1803883-I were conducted from 9/15/2025 to 9/18/2025.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 24, 2025
Visit Reason
A complaint investigation for complaint #123120-C was conducted on February 24, 2025.
Complaint Details
Complaint #123120-C was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance at the time of the investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 29, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was certified in compliance effective August 29, 2024, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 1
Date: Aug 28, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey from August 25, 2024 to August 28, 2024.
Findings
The facility failed to meet professional standards in medication administration for 2 residents, specifically regarding improper priming and injection technique of insulin flex pens by nursing staff.
Deficiencies (1)
Failed to prime the insulin flex pen with 2 units prior to dosing and did not keep the needle under the skin for the recommended 6 seconds to ensure full dose delivery for 2 residents.
Report Facts
Census: 57
Units of insulin dialed: 16
Units of insulin dialed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Bergen-Jackson | Administrator | Signed the plan of correction |
| Director of Nursing | Interviewed regarding insulin pen injection expectations | |
| Staff A, Registered Nurse | Observed administering insulin incorrectly to residents #9 and #25 |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 24, 2024
Visit Reason
The document is a Plan of Correction following acceptance of a credible allegation of substantial compliance for Oaknoll Retirement Residence.
Findings
The facility was found to be in substantial compliance and will be certified in compliance effective April 25, 2024. No specific deficiencies are detailed in this document.
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 5
Date: Apr 4, 2024
Visit Reason
The inspection was the facility's Annual Recertification Survey conducted from April 1, 2024 through April 4, 2024 to assess compliance with federal regulations.
Findings
The survey identified multiple deficiencies related to baseline care plans, care plan timing and revision, free of accident hazards, medication storage and labeling, hospice services, and coordination of hospice care. Immediate corrective actions and plans of correction were implemented to address these issues.
Deficiencies (5)
Failure to develop and implement a baseline care plan for each resident within 48 hours of admission.
Failure to ensure care plans were comprehensively reviewed, revised, or followed for selected residents.
Failure to ensure the resident environment was free of accident hazards and to provide adequate supervision and assistance devices to prevent accidents.
Failure to ensure secure storage of medications, including locked medication carts and double locks for schedule 4 medications.
Failure to ensure hospice services were properly coordinated, including written agreements and communication between hospice and facility staff.
Report Facts
Census: 57
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Bergen-Jackson | Administrator | Named in relation to baseline care plan deficiency and plan of correction. |
| Sara Ruhlmann | Director of Nursing | Named in relation to baseline care plan deficiency, fall prevention program, and coordination of hospice services. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 6, 2023
Visit Reason
A complaint investigation for Complaint #117116-C was conducted from November 30, 2023 to December 6, 2023.
Complaint Details
Complaint #117116-C was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 1, 2022
Visit Reason
An Annual Recertification Survey and investigation of Complaint #105378-C was conducted from November 28, 2022 to December 1, 2022.
Complaint Details
Investigation of Complaint #105378-C was conducted during the survey.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Renewal
Census: 52
Deficiencies: 3
Date: Aug 10, 2021
Visit Reason
The inspection was conducted as a Recertification Survey and investigation of Complaint #98852 and a Facility Self-Reported Incident #99045 from 8/2/21 to 8/10/21.
Complaint Details
Complaint #98852-C was partially substantiated and Incident #99045 was substantiated.
Findings
The facility was found to have deficiencies related to failure to thoroughly investigate areas of skin impairment with unknown etiology for one resident, failure to update care plans timely for two residents, and failure to investigate root causes of resident falls and implement targeted interventions. The complaint was partially substantiated and the incident was substantiated.
Deficiencies (3)
Failure to ensure identified areas of skin impairment with unknown etiology were thoroughly investigated for 1 of 1 resident reviewed.
Failure to update the Care Plan for 2 out of 5 residents reviewed.
Failure to investigate root cause of residents falls and implement targeted interventions for 2 of 7 residents investigated for falls.
Report Facts
Resident census: 52
Residents reviewed for care plan deficiency: 5
Residents investigated for falls: 7
Residents reviewed for skin impairment: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Bergen-Jackson | Administrator | Named in relation to the initial comments and plan of correction signature |
| Staff B | Licensed Practical Nurse (LPN) | Interviewed regarding skin impairment investigation |
| Staff A | Registered Nurse (RN) | Interviewed regarding process for injury of unknown origin |
| Director of Nursing (DON) | Interviewed regarding nursing staff process for injury of unknown origin and care plan expectations | |
| Assistant Director of Nursing (ADON) | Interviewed regarding care plan and fall interventions | |
| Staff C | Certified Nursing Assistant (CNA) | Interviewed regarding resident care and observations |
| Staff D | Certified Nursing Assistant (CNA) | Interviewed regarding resident observations |
| Staff E | Registered Nurse (RN) | Interviewed regarding resident behavior and falls |
| Staff G | Care Plan Coordinator | Interviewed regarding medication and fall interventions |
| Staff H | Social Services | Interviewed regarding care plan notes |
| Staff I | Restorative Aide | Interviewed regarding resident care and falls |
Inspection Report
Abbreviated Survey
Census: 45
Deficiencies: 0
Date: Jun 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total Residents: 45
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