Inspection Reports for Rotary Senior Living

620 SE 5th St, Eagle Grove, IA 50533, United States, IA, 50533

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Inspection Report Summary

The most recent inspection on September 9, 2024, identified a deficiency related to the alarm system in the secured memory care area, which was not operating properly and led to a tenant eloping. Earlier inspections showed additional deficiencies involving staff training, documentation, service plan development, and nurse reviews, with several substantiated complaints. The main issues have involved safety measures in the dementia program and compliance with care planning and staff training requirements. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The record shows some ongoing challenges with regulatory compliance, but corrective actions were implemented following the most recent findings.

Deficiencies (last 3 years)

Deficiencies (over 3 years) 1.7 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

61% better than Iowa average
Iowa average: 4.4 deficiencies/year

Deficiencies per year

4 3 2 1 0
2019
2020
2024

Census

Latest occupancy rate 11 residents

Based on a September 2024 inspection.

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

Census over time

0 5 10 15 20 Sep 2019 Dec 2020 Jan 2024 Sep 2024

Inspection Report

Complaint Investigation
Census: 11 Deficiencies: 1 Date: Sep 9, 2024

Visit Reason
The inspection was conducted following the investigation of Incident #123222-I related to a tenant eloping from the secured memory care area.

Complaint Details
The investigation was triggered by Incident #123222-I involving Tenant #1 eloping from the secured memory care area on 08/29/24. The complaint was substantiated as the alarm system was found not to be working properly.
Findings
The facility failed to ensure the alarm system connected to each exit door in the dementia-specific program operated properly, resulting in a tenant eloping. Corrective actions included door realignment, installation of an audible door alarm system, updated door check policies, staff education, and implementation of systematic long-term solutions.

Deficiencies (1)
The program failed to ensure the alarm system connected to each exit door in the dementia-specific program operated properly.
Report Facts
Census: 11 Number of tenants with cognitive impairment: 11 Number of tenants without cognitive impairment: 0 Incident date: Aug 29, 2024

Employees mentioned
NameTitleContext
Diane CaspersonAdministratorSigned the inspection report
Staff BInterviewed regarding tenant elopement and door alarm system
Staff CInterviewed regarding tenant elopement
Nursing SupervisorContacted department staff and educated them on new door check protocol

Inspection Report

Complaint Investigation
Census: 14 Deficiencies: 4 Date: Jan 31, 2024

Visit Reason
The inspection was conducted to investigate complaints #113691-C, #117974-C, and #112850-C and during recertification to determine compliance with certification for an Assisted Living Program for People with Dementia.

Complaint Details
The inspection was triggered by complaints #113691-C, #117974-C, and #112850-C. The findings were substantiated as the program failed in multiple regulatory requirements related to staff training, documentation, service plans, and nurse reviews.
Findings
The program failed to ensure certified and noncertified staff received training regarding service plan tasks, failed to document doctor-ordered tasks on medication administration records, failed to develop service plans prior to admission and based on evaluations, and failed to complete nurse reviews for tenants as required.

Deficiencies (4)
Failed to ensure certified and noncertified staff received training regarding service plan tasks such as straight catheterization.
Failed to document doctor-ordered tasks on medication administration records (MARs).
Failed to develop service plans prior to admission and ensure they were based on evaluations.
Failed to complete nurse reviews for tenants at least every 90 days or after significant change in condition.
Report Facts
Number of tenants with cognitive impairment: 14 Number of tenants without cognitive impairment: 0 Frequency of straight catheterization: 4 Date of last 90-day nurse review for Tenant C-1: Dec 29, 2021 Admission date Tenant C-2: Dec 1, 2023 Admission date Tenant #1: Apr 29, 2022

Employees mentioned
NameTitleContext
Diane CaspersonRN, BSN, LNHASigned Plan of Correction as Residential Care Facility representative
Staff DReported assisting Tenant C-1 with straight catheterization without training
AdministratorConfirmed findings related to delegation and documentation failures
Staff BConfirmed Tenant #1 had no service plan prior to 10/4/23
LPNConfirmed Tenant #1 had no nurse reviews on record

Inspection Report

Original Licensing
Census: 4 Deficiencies: 0 Date: Dec 8, 2020

Visit Reason
Initial certification visit conducted to determine compliance with certification of an Assisted Living Program for People with Dementia and to perform an onsite infection control survey.

Findings
No regulatory insufficiencies were cited during the initial certification visit or the onsite infection control survey.

Report Facts
Number of tenants without cognitive disorder: 0 Number of tenants with cognitive disorder: 4 Total census: 4

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Sep 26, 2019

Visit Reason
The visit was conducted as an on-site investigation of Complaint #85219-C filed with the Department.

Complaint Details
Complaint #85219-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of Complaint #85219-C. The census at the time of the complaint was 1, but was 0 at the time of the investigation.

Report Facts
Number of tenants without cognitive disorder: 0 Number of tenants with cognitive disorder: 0 Total Census of Assisted Living Program for People with Dementia: 0 Census at time complaint was filed: 1

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