Inspection Report Summary
The most recent inspection on January 9, 2025, cited a deficiency related to the improper disposal and reuse of medication from a deceased tenant. Earlier inspections showed a mix of findings, including issues with individualized service plans, staffing supervision, and medication practices, as well as some substantiated complaints involving mold and tenant evaluations. The main themes across deficiencies involved medication management and service plan documentation, with occasional concerns about staffing and environmental conditions. Complaint investigations were mostly unsubstantiated except for the medication reuse issue and a past mold complaint. The inspection history shows some recurring issues with medication and service plans, but more recent reports indicate fewer and more isolated deficiencies.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
1.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
61% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
25 residents
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 1
Jan 9, 2025
Visit Reason
The inspection was conducted to investigate Complaint #121471-C and to conduct a recertification visit to determine compliance with certification of an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the investigation of Incident 121687-I. However, a regulatory insufficiency was cited related to the program's failure to consistently follow policy and procedure for disposal of medications, specifically involving the use of a deceased tenant's medication for another tenant.
Complaint Details
The complaint investigation found that the program used a deceased tenant's medication for Tenant #3, which was inappropriate. The complaint was substantiated by record reviews and staff interviews.
Deficiencies (1)
| Description |
|---|
| Program failed to consistently follow policy and procedure for disposal of medications, including using medication from a deceased tenant for another tenant. |
Report Facts
Number of tenants without cognitive impairment: 24
Number of tenants with cognitive impairment: 1
Total census: 25
Dates of staff education: Jan 10, 2025
Compliance date: Jan 28, 2025
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 0
Dec 6, 2023
Visit Reason
Investigation of Complaint #112958-C at Regency Assisted Living.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Complaint Details
Complaint #112958-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive impairment: 28
Number of tenants with cognitive impairment: 0
Total census: 28
Inspection Report
Renewal
Census: 46
Deficiencies: 2
Feb 1, 2023
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for an Assisted Living Program and to investigate Complaint #107728-C.
Findings
The inspection found a regulatory insufficiency related to individualized service plans for tenants, specifically that the program failed to list identified needs on service plans for three tenants reviewed. Another deficiency was found in staffing supervision related to a discharged tenant with dementia.
Complaint Details
The inspection included investigation of Complaint #107728-C. No regulatory insufficiencies were cited during the investigation of Incident #107729-I.
Severity Breakdown
A 395: 1
A 530: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| The service plan shall be individualized and indicate the tenant's identified needs and preferences for assistance. The program failed to list the identified needs on the service plans of 3 tenants reviewed. | A 395 |
| A dementia-specific assisted living program shall have staff monitoring tenants as indicated in each tenant's service plan. The program failed to supervise 1 of 1 discharged tenants reviewed according to her service plan. | A 530 |
Report Facts
Number of tenants without cognitive disorder: 46
Number of tenants with cognitive disorder: 0
Total census: 46
Date survey completed: Feb 1, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Black | Assisted Living Director | Signed the report and confirmed findings on 2/1/23 |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 0
Dec 3, 2020
Visit Reason
The visit was conducted to investigate Complaint #91001-C and to perform a recertification visit to determine compliance with certification for an Assisted Living Program.
Findings
There were no regulatory insufficiencies found during the complaint investigation or the recertification visit.
Complaint Details
Complaint #91001-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 0
Total census: 28
Inspection Report
Renewal
Census: 27
Deficiencies: 0
Jun 26, 2018
Visit Reason
The visit was a recertification visit conducted to determine compliance with certification rules for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification visit for the Assisted Living Program.
Report Facts
Number of tenants without cognitive disorder: 26
Number of tenants with cognitive disorder: 1
Total census: 27
Inspection Report
Monitoring
Census: 26
Deficiencies: 0
Jun 20, 2016
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation to review recertification documents and compliance with certification requirements for Regency Assisted Living.
Findings
No regulatory insufficiencies were found during the evaluation. The review of recertification documents was completed and accepted, and the State Fire Marshal's inspection report and Facility Engineer's approval of evacuation plans were received.
Report Facts
Number of tenants without cognitive disorder: 25
Number of tenants with cognitive disorder: 1
Total Population of Program at time of on-site: 26
Total census of Assisted Living Program: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Signed letter regarding the Final Recertification Monitoring Evaluation Report |
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 8
Jul 30, 2014
Visit Reason
The inspection was conducted as a Final Complaint Investigation and Recertification Monitoring Evaluation following a complaint and to evaluate regulatory insufficiencies in tenant evaluation, service plans, medications, nurse review, food service, and staffing at Regency Assisted Living.
Findings
The report identified multiple regulatory insufficiencies including incomplete evaluations of tenants, inadequate service plans, improper medication administration practices, insufficient nurse reviews, food service licensing issues, staffing training deficiencies, and structural concerns related to mold in the kitchen area. Some complaints were substantiated while others were not.
Complaint Details
Complaint #49025-C alleged mold in the kitchen area and improper equipment during cleaning of mold. The mold complaint was substantiated with findings of mold and moisture damage in kitchen cabinetry. The equipment complaint was not substantiated.
Deficiencies (8)
| Description |
|---|
| Evaluations of function, cognition, and health were not completed within 30 days of admission for Tenant #1 and were not completed at least annually for Tenant #2. |
| Service plans were not completed timely or based on evaluations, and interventions for prevention of falls and refusal of care were inadequate. |
| Medication administration did not follow accepted practices including failure to cleanse hands, improper handling of insulin pens, and unsecured insulin pens. |
| Nurse reviews were not completed with significant changes of condition and documentation was lacking. |
| The assisted living program did not have a food license and stored beverages in containers larger than single-serving size. |
| Staff files lacked documentation of competency and training by a Registered Nurse. |
| Mold was found in the kitchen cabinetry area, with moisture damage and musty odors noted; corrective actions were taken. |
| Dust from construction in the dining room caused respiratory concerns; masks were provided and cleaning was performed. |
Report Facts
Total census: 23
Tenants without cognitive disorder: 22
Tenants with cognitive disorder: 1
Tenant meeting attendance: 18
Staff files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sara Squire | Director of Nursing | Named as recipient of report and referenced in medication and nurse review findings |
| Lori Miner | RN BSN Monitor | Conducted the monitoring visit and observations |
| Rose Boccella | Program Coordinator | Author of the cover letter and contact for the report |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 0
Mar 28, 2013
Visit Reason
The visit was conducted as a complaint/incident investigation following allegations related to staffing levels and falsified employer timecards at Regency Assisted Living.
Findings
No regulatory insufficiencies were identified during the investigation. Staffing levels were found appropriate with no issues of short staffing, and the Department does not have regulatory authority over employees' timesheets.
Complaint Details
The complaint alleged insufficient staffing to meet tenants' needs and falsification of employer timecards. Both allegations were investigated with no regulatory insufficiencies found. The staffing pattern was documented and tenant interviews indicated satisfaction with staff.
Report Facts
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 0
Total census of Assisted Living Program: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor who provided documentation of staffing pattern during investigation |
| Megan Toney | Administrator | Administrator of Regency Assisted Living named in the report |
Inspection Report
Monitoring
Census: 18
Deficiencies: 3
Jan 19, 2012
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review the Plan of Correction and ensure compliance with regulatory requirements for the Regency Assisted Living program in Norwalk, IA.
Findings
The report found multiple regulatory insufficiencies related to tenant evaluations, service plans, and nurse reviews, including failure to complete evaluations within required timeframes and incomplete service plans. The Plan of Correction submitted was accepted by the Department of Inspections and Appeals.
Deficiencies (3)
| Description |
|---|
| Failure to complete functional, cognitive, and health evaluations within 30 days of occupancy and annually. |
| Service plans were not updated within 30 days of admission or to reflect changes in tenant condition, including missing interventions for anxiety, pacing, and swallowing difficulties. |
| Nurse reviews were incomplete, lacking documentation of medication evaluations and failure to monitor medications every 90 days. |
Report Facts
Number of tenants without cognitive disorder: 18
Number of tenants with cognitive disorder: 0
Total population of program at time of on-site: 18
Number of tenants interviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Megan Toney | RN Director | Named as Director of Regency Assisted Living |
| Lori Miner | RN BSN | Monitor conducting the evaluation |
| Rose Boccella | Program Coordinator | Signed letter regarding certification |
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 1
Jul 23, 2010
Visit Reason
A complaint investigation on-site visit was conducted at Regency Assisted Living on July 23, 2010, to investigate allegations related to a tenant who left the program and showed up at a personal residence several blocks away, with concerns about a possible fall.
Findings
The investigation found that the tenant, an 83-year-old with dementia, had left the program premises but was safely returned. The program had policies and staff understanding to manage missing tenants. A regulatory insufficiency was noted due to failure to notify the director or designee within 24 hours of the tenant eloping from the program.
Complaint Details
Complaint Allegation: Tenant #1 left the program and showed up at a personal residence several blocks away, was confused, had a bump to the head, and may have fallen. Local police transported the tenant back to the program. The tenant had dementia and was discharged from the program after the incident.
Deficiencies (1)
| Description |
|---|
| Regulatory Insufficiency: The director or the director’s designee shall be notified within 24 hours, or the next business day, by the most expeditious means available when a tenant elopes from a program. |
Report Facts
Tenant count without cognitive disorder: 22
Tenant count with cognitive disorder: 0
Total population: 22
Civil penalty amount: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor of the complaint investigation |
| Connie Schaffer | Certification Coordinator | Contact person for questions regarding the report and findings |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter related to the complaint investigation |
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