Inspection Report Summary
The most recent inspection on April 30, 2025, found no deficiencies during the recertification visit. Earlier inspections showed a generally positive compliance history with occasional deficiencies related primarily to tenant evaluations, service plan updates, and nursing reviews, particularly noted in a complaint investigation from March 29, 2023. Prior complaint investigations also identified issues with medication administration and documentation, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. Most complaint investigations were unsubstantiated, except for some substantiated findings related to care planning and medication management in earlier years. The facility’s recent clean inspection suggests improvement following prior citations in tenant care documentation and service planning.
Deficiencies (last 12 years)
Deficiencies (over 12 years)
1.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
67 residents
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 67
Deficiencies: 0
Apr 30, 2025
Visit Reason
Recertification visit conducted to determine compliance with certification rules for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification visit.
Report Facts
Number of tenants without cognitive impairment: 61
Number of tenants with cognitive impairment: 6
Total census: 67
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 0
Mar 12, 2024
Visit Reason
Investigation of Complaint #119396-C to assess regulatory compliance at Heritage at Fox Run Assisted Living.
Findings
No regulatory insufficiencies were cited during the complaint investigation. The program met criteria to be an Assisted Living Program for People with Dementia for the last two recertification visits.
Complaint Details
Complaint #119396-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive impairment: 62
Number of tenants with cognitive impairment: 9
Total census: 71
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 5
Mar 29, 2023
Visit Reason
The inspection was conducted due to the investigation of Complaint #110010-C, Incident 109812-I, and the recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
The program failed to complete required tenant evaluations within 30 days of occupancy for 4 of 6 tenants, failed to evaluate tenants with significant change for 2 of 6 tenants, failed to develop service plans based on evaluations for 5 of 6 tenants, failed to ensure signatures on updated service plans for all 6 tenants, and failed to complete required 90-day nurse reviews for all 6 tenants.
Complaint Details
The inspection was triggered by Complaint #110010-C and Incident 109812-I. The complaint investigation found multiple regulatory insufficiencies related to tenant evaluations, service plans, and nurse reviews.
Deficiencies (5)
| Description |
|---|
| Failed to complete evaluations within 30 days of occupancy for 4 of 6 tenants. |
| Failed to evaluate tenants with significant change for 2 of 6 tenants. |
| Failed to develop service plans based on evaluations for 5 of 6 tenants. |
| Failed to ensure signatures on updated service plans within required timeframes for all 6 tenants. |
| Failed to complete 90-day nurse reviews for all 6 tenants. |
Report Facts
Number of tenants without cognitive impairment: 49
Number of tenants with cognitive impairment: 10
Total census: 59
Tenants reviewed for evaluations: 6
Tenants with missing 30-day evaluations: 4
Tenants with missing evaluations for significant change: 2
Tenants with missing service plans based on evaluations: 5
Tenants without signed updated service plans: 6
Tenants without completed 90-day nurse reviews: 6
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 0
Mar 8, 2022
Visit Reason
The inspection was conducted to investigate Incident #102946-I at the assisted living facility.
Findings
No regulatory insufficiencies were cited during the investigation of the incident.
Complaint Details
Investigation of Incident #102946-I found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 51
Number of tenants with cognitive disorder: 9
Total Population of Program at time of on-site: 60
TOTAL census of Assisted Living Program: 60
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 0
Mar 8, 2022
Visit Reason
Investigation of Incident #102946-I at Heritage at Fox Run Assisted Living.
Findings
No regulatory insufficiencies were cited during the investigation of the incident.
Complaint Details
Investigation of Incident #102946-I found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 51
Number of tenants with cognitive disorder: 9
Total Population of Program at time of on-site: 60
TOTAL census of Assisted Living Program: 60
Inspection Report
Renewal
Census: 64
Deficiencies: 0
Mar 9, 2021
Visit Reason
The visit was conducted as a recertification to determine compliance with certification of an Assisted Living Program, including an onsite infection control survey and investigation of several incidents and a complaint.
Findings
No regulatory insufficiencies were cited during the recertification visit, the infection control survey, or the investigations of incidents and complaint.
Report Facts
Number of tenants without cognitive disorder: 55
Number of tenants with cognitive disorder: 9
Total Population of Program at time of on-site: 64
Inspection Report
Renewal
Census: 65
Deficiencies: 0
Jun 19, 2018
Visit Reason
Recertification conducted to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification inspection.
Report Facts
Number of tenants without cognitive disorder: 62
Number of tenants with cognitive disorder: 3
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 0
Jun 14, 2016
Visit Reason
Investigation of Incident #60403-I and recertification to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #60403-I or during the recertification conducted to determine compliance with certification for the Assisted Living Program.
Complaint Details
Investigation of Incident #60403-I found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 59
Number of tenants with cognitive disorder: 9
Total Population of Program at time of on-site: 68
Total census of Assisted Living Program: 68
Inspection Report
Monitoring
Census: 73
Deficiencies: 0
Apr 7, 2015
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were found during this evaluation. The program was reviewed and accepted, and it did not meet the definition of dementia-specific during this recertification visit.
Report Facts
Number of tenants without cognitive disorder: 69
Number of tenants with cognitive disorder: 4
Total Population of Program at time of on-site: 73
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 0
Nov 7, 2012
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding an allegation of bed bugs infestation in a tenant's apartment at Fox Run Assisted Living.
Findings
The investigation found evidence of bed bugs in the tenant's apartment and surrounding areas, which were treated and remediated through pest control measures and replacement of affected items. No regulatory insufficiencies were identified.
Complaint Details
The complaint alleged a case of bed bugs in Tenant #1's apartment. The onsite investigation confirmed the presence of bed bugs, leading to treatment and remediation efforts including heat treatment, chemical treatment, and replacement of bedding and furniture. Tenant interviews indicated satisfaction with the program's response. No regulatory insufficiencies were found.
Report Facts
Number of tenants without cognitive disorder: 61
Number of tenants with cognitive disorder: 10
Total census of Assisted Living Program: 71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Author of the cover letter and contact for the report |
| Hal L. Chase | RN BSN MPH | Monitor for the complaint/incident investigation |
Inspection Report
Monitoring
Census: 72
Deficiencies: 2
Feb 29, 2012
Visit Reason
The report is a Final Recertification Monitoring Evaluation Report for Fox Run Assisted Living, documenting a monitoring visit conducted to evaluate compliance with regulatory requirements and the Plan of Correction submitted by the facility.
Findings
The report found regulatory insufficiencies related to the exit door alarm system and record checks, specifically that not all doors were alarmed as required for a dementia-specific program and that background checks for a staff member were incomplete. The Department of Inspections and Appeals accepted the facility's Plan of Correction and Request for Reconsideration.
Deficiencies (2)
| Description |
|---|
| An operating alarm system shall be connected to each exit door in a dementia-specific program; not all doors were alarmed as required. |
| Background check for a medication manager was incomplete; the program did not provide documentation of completion of dependent adult abuse registry check. |
Report Facts
Census: 72
Number of tenants with cognitive disorder: 11
Number of tenants without cognitive disorder: 61
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 3
Jan 4, 2011
Visit Reason
A complaint investigation was conducted at Fox Run Assisted Living on January 4, 2011, following allegations related to tenant care, service plan, and medication administration.
Findings
The investigation found regulatory insufficiencies in the evaluation of tenants, service plans, and medication administration, including tenant refusal of medications and assistance, inadequate functional and cognitive evaluations, and improper medication management.
Complaint Details
Complaint Allegation #32188-C involved a tenant hospitalized for hypokalemia, alcoholism, and malnutrition, with findings of alcohol and medication misuse, refusal of care, and inadequate program response. The complaint investigation confirmed multiple regulatory insufficiencies.
Deficiencies (3)
| Description |
|---|
| Failure to complete functional, cognitive, and health evaluations when tenant's status changed or as required. |
| Service plans were not updated to reflect changes in tenant health status or interventions related to refusals and medical conditions. |
| Medication administration was not conducted according to regulatory requirements, including failure to observe medication intake and improper handling of unused medications. |
Report Facts
Census: 63
Tenants with dementia: 13
Tenants without cognitive disorder: 50
Civil penalty amount: 1000
Alcohol bottles found: 15
OTC medications found: 40
Prescription medications found: 300
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the complaint investigation |
| Jim Berkley | Program Coordinator | Contact person for appeals and civil penalty matters |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 5
Oct 25, 2010
Visit Reason
A complaint investigation on-site visit was conducted at Fox Run Assisted Living on October 25, 2010, to investigate allegations related to tenant care and regulatory compliance.
Findings
The investigation found multiple regulatory insufficiencies including failure to complete functional, cognitive, and health evaluations after significant changes in tenant health status, incomplete service plan updates, a medication error involving an overdose of morphine, and deficiencies in food service and staffing documentation.
Complaint Details
Complaint Allegation #29598-C involved a tenant with multiple bruises and falls not properly documented by the program. Complaint Allegation #30397-C involved a staff medication error resulting in an overdose of morphine to a tenant.
Deficiencies (5)
| Description |
|---|
| Failure to complete functional, cognitive and health evaluations with a significant change in health status related to tenant falls and injuries. |
| Failure to update tenant service plans following significant changes including falls, hospitalizations, and hospice admissions. |
| Medication error where staff administered 5ml of Roxanol instead of the ordered 0.25ml, resulting in an overdose of morphine. |
| Personnel files lacked documentation of orientation on sanitation and safe food handling prior to handling food. |
| Staff personnel files lacked documentation of competency in performing ADLs to the program RN. |
Report Facts
Current number of tenants with dementia: 12
Current number of tenants without cognitive disorder: 50
Total population: 62
Tenant meeting attendance: 37
Medication dosage error: 5
Medication ordered dosage: 0.25
Staff files reviewed: 5
Tenant files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the complaint investigation |
| Staff #1 | Licensed Practical Nurse (LPN) | Administered incorrect medication dosage resulting in overdose |
| Staff #6 | Staff member involved in food service and personal care | |
| Staff #7 | Staff member involved in food service and personal care | |
| Staff #8 | Staff member involved in food service and personal care |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 1
Oct 13, 2004
Visit Reason
A complaint investigation was conducted due to an incident where a tenant left the assisted living program without signing out and became lost near a local golf course clubhouse.
Findings
The investigation found that the tenant had cognitive impairment and a history of wandering, with no alarms or monitors on exit doors. The tenant eloped without notifying staff and was found incontinent. The program failed to follow up with the physician regarding medication effects. The tenant's family opted for increased visual checks to prevent further incidents.
Complaint Details
The complaint involved a tenant who left the program to visit a nearby golf course clubhouse, took a wrong turn, and was found lost at an apartment complex. The tenant had cognitive impairment and a history of wandering. The tenant eloped without signing out or notifying staff. There were no alarms on exit doors. The tenant was found incontinent and the program failed to follow up on medication administration. The family chose increased visual checks and possible discharge if elopement recurs.
Severity Breakdown
Regulatory Insufficiency: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The program RN did not follow-up with the physician or family regarding the effects of the medication and whether the tenant should continue the medication. | Regulatory Insufficiency |
Report Facts
Current number of tenants without cognitive disorder: 19
Current number of tenants with cognitive disorder: 2
Total Population: 21
Visual check frequency: 4
Medication supply duration: 30
Date of medication sample depletion: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasey C. Harrison | LPN | Named as tenant's nurse in the assisted living program |
| Sherrie McDonald | RN | Monitor conducting the complaint investigation |
Inspection Report
Monitoring
Census: 19
Deficiencies: 7
Sep 16, 2004
Visit Reason
An on-site monitoring evaluation was conducted at Fox Run Assisted Living to assess compliance with Iowa assisted living program regulations as part of the initial certification monitoring process.
Findings
The evaluation identified multiple regulatory insufficiencies including failure to evaluate tenants' functional and cognitive status as needed, failure to transfer a tenant who chronically wanders into danger, lack of updated individualized service plans, improper medication storage, staff lacking appropriate chauffeur licenses for tenant transportation, inadequate individualized activities, and incomplete employee criminal background checks prior to hire.
Complaint Details
There were no substantiated complaints this certification period.
Deficiencies (7)
| Description |
|---|
| The program did not evaluate each tenant’s functional, cognitive, and health status as needed to determine if any modifications to services were needed. |
| The program did not transfer a tenant who, despite intervention, chronically wanders into danger. |
| The program did not update individualized service plans to meet the needs of tenants #1, #2, #3 as identified by the program nor did the plans include expected outcomes. |
| Program did not keep medications in a locked place or container that was not accessible to persons other than employees responsible for administration and storage of such medications. |
| The program staff does not have the appropriate class “D” chauffeur’s license or a Commercial Drivers License (CDL) for transporting tenants. |
| The program does not provide appropriate activities that reflect meaning and purpose for the tenant. |
| The program did not complete appropriate criminal background checks prior to hiring employees. |
Report Facts
Current number of tenants without cognitive disorder: 17
Current number of tenants with cognitive disorder: 2
Total General Population: 19
Employee records reviewed: 4
Tenant files reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasey Harrison | LPN | Named as contact for Fox Run Assisted Living |
| Sherrie McDonald | RN | Monitor conducting the evaluation |
| Hal L. Chase | RN, BSN, MPH | Monitor conducting the evaluation |
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