Inspection Reports for
Quartet – A Senior Living Village

IA, 52722

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 6.7 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

52% worse than Iowa average
Iowa average: 4.4 deficiencies/year

Deficiencies per year

12 9 6 3 0
2023
2024
2025

Census

Latest occupancy rate 28 residents

Based on a September 2025 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Occupancy over time

7 14 21 28 35 Sep 2023 Feb 2024 Sep 2024 May 2025 Sep 2025

Inspection Report

Complaint Investigation
Census: 28 Deficiencies: 3 Date: Sep 16, 2025

Visit Reason
The inspection was conducted to investigate complaints #129627-I, #129504-C, and #130350-I, and to conduct a recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.

Complaint Details
The investigation included complaints #129627-I and #129504-C, which had no regulatory insufficiencies cited. The deficiencies cited were related to complaint #130350-I and the recertification visit.
Findings
No regulatory insufficiencies were cited for complaints #129627-I and #129504-C. However, deficiencies were found related to criteria for admission/retention of tenants requiring two-person assistance, and failures in updating and individualizing service plans for tenants, including those with behavioral issues and mobility needs.

Deficiencies (3)
Program retained 2 of 4 tenants who regularly required two staff for transfers, violating criteria for admission/retention.
Program failed to update the service plan for 1 of 4 residents with a fractured spine within 30 days of a significant change.
Program failed to ensure service plans included the needs of 3 of 4 tenants reviewed, including behavioral and mobility needs.
Report Facts
Total census: 28 Tenants requiring two-person assistance: 2 Residents reviewed for service plans: 4 Tenants with unmet service plan needs: 3 Date of incident report: Aug 29, 2025

Inspection Report

Complaint Investigation
Census: 29 Deficiencies: 2 Date: May 21, 2025

Visit Reason
The inspection was conducted to investigate complaints #128133-C, 127571-C, and 125640-C, as well as Incident #126023-I at Quartet Senior Living MC.

Complaint Details
The visit was complaint-related, investigating complaints #128133-C, 127571-C, and 125640-C. No regulatory insufficiencies were cited during the investigation of Incident #126023-I.
Findings
No regulatory insufficiencies were found related to Incident #126023-I. However, regulatory insufficiencies were cited for failure to implement a system or written procedure to address tenant emergency needs for cognitively impaired tenants, and failure to ensure staff received required dementia-specific education within 30 days of employment.

Deficiencies (2)
Failed to implement a system or written procedure to address tenant emergency needs when tenants are unable to use/understand Personal Emergency Response System (PERS)/pendant, potentially affecting 29 tenants.
Failed to ensure staff received a minimum of eight hours of dementia-specific education within 30 days of employment, affecting 2 staff members.
Report Facts
Number of tenants without cognitive impairment: 5 Number of tenants with cognitive impairment: 24 Total census: 29 Staff members without required dementia training: 2

Employees mentioned
NameTitleContext
Staff AFailed to complete eight hours of dementia-specific training within 30 days of employment
Staff BFailed to complete eight hours of dementia-specific training within 30 days of employment

Inspection Report

Complaint Investigation
Census: 21 Deficiencies: 2 Date: Sep 9, 2024

Visit Reason
The inspection was conducted as an investigation into Complaint #121670-C regarding regulatory insufficiencies at Quartet Senior Living MC.

Complaint Details
The visit was triggered by Complaint #121670-C. The complaint involved retention of a tenant who was aggressive and dangerous, and failure to provide timely notice and service plans. The findings were substantiated by interviews and record reviews.
Findings
The investigation found that the program retained a tenant (Tenant C1) who displayed verbal and physical aggression despite interventions, resulting in harm to another tenant. Additionally, the program failed to develop and sign a preliminary service plan prior to occupancy for another tenant (Tenant #3).

Deficiencies (2)
The program retained a tenant who displayed verbal and physical aggression and was dangerous to self or others.
Failure to ensure a preliminary service plan was developed and signed prior to the signing of an occupancy agreement for one tenant.
Report Facts
Total census: 21 Tenants without cognitive impairment: 3 Tenants with cognitive impairment: 18 Discharge date of Tenant C1: Jul 5, 2024 Date of service plan for Tenant #3: Aug 26, 2024 Date occupancy agreement signed for Tenant #3: Aug 28, 2024

Employees mentioned
NameTitleContext
Regional Director of OperationsConfirmed findings on 9/9/24 at 11:00 AM
Assistant Director of NursingUpdated Tenant #3's daughter and coordinated move to Memory Care
Resident Services DirectorResident Services Director (RSD)Trained staff on communication and monitoring aggression; monitors compliance

Inspection Report

Complaint Investigation
Census: 14 Deficiencies: 7 Date: Feb 21, 2024

Visit Reason
Investigation of Complaint #118032-C and revisit to the initial certification visit at Quartet Senior Living MC.

Complaint Details
The visit was triggered by Complaint #118032-C and included a revisit to the initial certification visit.
Findings
The program failed to complete incident reports for all accidents or unusual occurrences, failed to administer medications as prescribed, failed to complete evaluations and nurse's notes as needed with significant changes, and failed to update service plans timely and accurately. Additionally, a nurse review was not completed following a significant health change for a discharged tenant.

Deficiencies (7)
Failed to complete incident reports for all accidents or unusual occurrences affecting tenants.
Failed to administer medications as prescribed for a discharged tenant.
Failed to complete evaluations as needed with significant change for current and discharged tenants.
Failed to document nurse's notes by exception for current tenants.
Failed to update service plans as needed for current and discharged tenants.
Failed to update and sign service plans within 30 days of tenant occupancy for a recently admitted tenant.
Failed to complete nurse reviews as needed with a change in health status for a discharged tenant.
Report Facts
Number of tenants without cognitive impairment: 1 Number of tenants with cognitive impairment: 13 Total census: 14 Medication Incident Report date: 2023 Medication administration record dates: 2023 Admission date: 2023

Employees mentioned
NameTitleContext
Clinical DirectorInterviewed on 2/21/24 confirming incident reports, MARs, orders, evaluations, nurse's notes, service plans, and nurse reviews were provided for tenants reviewed.

Inspection Report

Complaint Investigation
Census: 18 Deficiencies: 6 Date: Sep 13, 2023

Visit Reason
The inspection was conducted as a complaint investigation (#112734-C) and an initial certification visit to determine compliance with certification of a Dedicated Dementia Specific Assisted Living Program.

Complaint Details
The inspection was triggered by Complaint #112734-C, which involved concerns about medication administration and other care issues.
Findings
The Program failed to follow established policies and procedures related to medication administration and blood glucose testing, failed to provide nurse delegated training within 30 days for some staff, failed to complete cognitive evaluations prior to occupancy for some tenants, failed to complete evaluations with significant change, and failed to update service plans to reflect tenant needs and behaviors. Additionally, a service plan was not signed within 30 days for one tenant.

Deficiencies (6)
Failed to follow established policies and procedures related to medication administration and blood glucose testing, including hand hygiene and medication omissions.
Failed to provide nurse delegated training within 30 days of employment for 2 of 3 staff reviewed.
Failed to complete cognitive evaluations prior to taking occupancy for 2 of 5 current tenants and 1 of 2 discharged tenants.
Failed to complete evaluations with significant change for 1 tenant who experienced multiple significant health and behavioral changes.
Failed to update service plans to reflect service needs and behavioral interventions for 5 current tenants and 2 discharged tenants.
Failed to obtain signed service plans within 30 days of occupancy for 1 tenant.
Report Facts
Total census: 18 Number of tenants without cognitive impairment: 5 Number of tenants with cognitive impairment: 13 Number of medication administration omissions: 15 Number of staff reviewed for nurse delegated training: 3 Number of tenants reviewed for cognitive evaluations: 5 Number of tenants reviewed for service plan updates: 5

Employees mentioned
NameTitleContext
Staff ADirect Care StaffFailed to receive nurse delegated training within 30 days
Staff BDirect Care StaffFailed to receive nurse delegated training within 30 days
Staff CObserved administering medications without proper hand hygiene
Clinical DirectorClinical DirectorConfirmed expectations for hand hygiene, nurse delegated training, evaluations, and service plans
Staff DProvided information about tenant relationships and behaviors
Staff EProvided information about tenant relationships and behaviors
Staff FLicensed Practical Nurse (LPN)Evaluator of Staff A's competency, not a registered nurse

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