Inspection Reports for Pennsylvania Place
One Pennsylvania Place, Ottumwa, IA, 52501
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 26, 2025, identified deficiencies related to delayed evaluations and service plan updates following a significant change in condition for one tenant. Earlier inspections showed a pattern of issues with timely and complete tenant evaluations, updating and signing service plans, and maintaining safe grounds. Complaint investigations were generally unsubstantiated except for the most recent case, which confirmed delays in updating care plans after health declines. There were no fines, immediate jeopardy findings, or enforcement actions listed in the available reports. The facility’s inspection history indicates ongoing challenges with documentation and care planning, with no clear improvement trend over time.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
2.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
33 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 2
Date: Jun 26, 2025
Visit Reason
The inspection was conducted as part of the investigation of Complaint #127298-C regarding regulatory insufficiencies at the assisted living program Pennsylvania Place.
Complaint Details
The visit was triggered by Complaint #127298-C. The complaint investigation found that Tenant #1's evaluations and service plan updates were not completed timely following significant health and functional decline.
Findings
The program failed to complete required evaluations and update service plans for Tenant #1 following a significant change in condition beginning around 3/08/25 and continuing after hospitalization. Tenant #1 experienced a marked decline in functional, cognitive, and health status, including increased assistance needs and erratic behaviors, but the evaluations and service plan updates were delayed until 5/09/25.
Deficiencies (2)
Failure to complete evaluations due to significant change in condition for 1 of 3 tenants reviewed (Tenant #1).
Failure to update the service plan within 30 days of significant change for 1 of 3 tenants reviewed (Tenant #1).
Report Facts
Number of tenants without cognitive impairment: 31
Number of tenants with cognitive impairment: 2
Total census: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Verified the program failed to complete updated assessments and service plan updates for Tenant #1. |
Inspection Report
Renewal
Census: 32
Deficiencies: 2
Date: Aug 12, 2024
Visit Reason
The visit was a recertification inspection conducted to determine compliance with certification rules for an Assisted Living Program.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #117506-C and #118553-C.
Findings
No regulatory insufficiencies were cited during the complaint investigations. However, regulatory insufficiencies were cited during the recertification visit related to failure to obtain required signatures on updated service plans for tenants with significant changes or within 30 days of occupancy.
Deficiencies (2)
Failed to obtain resident signature for a service plan updated for 1 of 1 tenant reviewed with a significant change (Tenant #4).
Failed to obtain signatures for 30-day service plans for 2 of 2 tenants reviewed who were admitted in the prior 3 months (Tenant #1 and Tenant #3).
Report Facts
Number of tenants without cognitive impairment: 29
Number of tenants with cognitive impairment: 3
Total census: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Hostetler | Executive Director | Signed the Plan of Correction letter. |
| Consultant Registered Nurse | Verified the program had not obtained required signatures for service plans (Tenant #4, Tenant #1, Tenant #3). No full name provided. | |
| Program RN | Confirmed missing signatures on service plans for Tenant #3. No full name provided. | |
| Director of Nursing | Mentioned in Plan of Correction as responsible for updating and signing service plans and re-education. |
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 7
Date: May 2, 2022
Visit Reason
The inspection was a recertification visit to determine compliance with certification for an Assisted Living Program, including completion of a complaint investigation.
Complaint Details
Complaint #98389-C was investigated and no regulatory insufficiencies were identified.
Findings
The investigation of Complaint #98389-C found no regulatory insufficiencies. However, the recertification visit identified multiple regulatory deficiencies including failure to complete incident reports, incomplete tenant evaluations within required timeframes, failure to update service plans as needed, lack of signatures on service plans, and unsafe building grounds due to deteriorated concrete in sidewalks and parking lot posing safety hazards.
Deficiencies (7)
Failure to follow policy and procedure related to completion of incident reports for a tenant who voiced suicidal ideation.
Failure to complete tenant evaluations within 30 days of occupancy for 2 of 3 tenants reviewed.
Failure to complete annual or as needed tenant evaluations for 2 of 4 tenants reviewed.
Failure to update service plans as needed for 4 of 4 tenants reviewed.
Failure to have service plan updated within 30 days signed and dated by all parties for 1 of 2 tenants reviewed.
Failure to have updated service plan signed and dated by all parties at least annually for 1 of 1 tenant reviewed.
Failure to maintain well-maintained, clean, safe, and sanitary grounds due to deteriorated concrete in sidewalks and parking lot posing safety hazards to tenants.
Report Facts
Census without cognitive disorder: 36
Census with cognitive disorder: 2
Total census: 38
Incident date: Mar 19, 2022
Incident date: Apr 3, 2022
Concrete bid date: Jul 5, 2021
Concrete repair measurement: 12
Concrete repair measurement: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed findings related to incident reports, tenant evaluations, service plans, and building conditions during interviews | |
| Staff A | Interviewed regarding tenant incident and condition of parking lot and sidewalk | |
| Assistant Director of Nursing | Signed service plans but service plans lacked tenant or legal representative signatures | |
| Executive Director | Provided information about concrete repair bids and follow-up |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 0
Date: May 4, 2021
Visit Reason
An onsite infection control survey and complaint #93826-C were completed at the facility.
Complaint Details
Complaint #93826-C was investigated and found to have no regulatory insufficiencies.
Findings
There were no regulatory insufficiencies cited during the inspection.
Report Facts
Number of tenants without cognitive disorder: 29
Number of tenants with cognitive disorder: 0
Total census of Assisted Living Program: 29
Inspection Report
Original Licensing
Census: 31
Deficiencies: 0
Date: Feb 12, 2020
Visit Reason
Initial certification visit conducted to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the initial certification visit for the Assisted Living Program.
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