Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Feb 20, 2025
Visit Reason
The visit was conducted to investigate complaints #123013-C and 126555-C at the assisted living facility.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints.
Complaint Details
Investigation of Complaints #123013-C and 126555-C found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive impairment: 39
Number of tenants with cognitive impairment: 2
Total census: 41
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 6
Jul 10, 2024
Visit Reason
The inspection was conducted to investigate multiple complaints (#118147-C, #118081-C, #118079-C, and #117958-C) and to perform a recertification visit to determine compliance with certification of an Assisted Living Program.
Findings
The program failed to ensure tenants were treated with dignity and respect, failed to retain communication logs for three years, did not fully evaluate or update service plans and conduct nurse reviews following significant changes in tenant conditions, and failed to include tenant preferences in service plans.
Complaint Details
The visit was triggered by complaints #118147-C, #118081-C, #118079-C, and #117958-C regarding tenant treatment and care issues.
Deficiencies (6)
| Description |
|---|
| Failure to ensure 4 of 4 tenants interviewed were treated with dignity and respect, including demeaning communication by the Clinical Manager. |
| Failure to retain communication logs for three years as required. |
| Failure to fully evaluate cognitive, health, and functional status after a change in condition for 1 discharged tenant. |
| Failure to update the service plan for 1 discharged tenant after a change in cognitive condition. |
| Failure to include tenant preferences in the service plan for 1 of 5 tenants reviewed. |
| Failure to complete a nurse review to assess health status following a change in condition for 1 discharged tenant. |
Report Facts
Number of tenants without cognitive impairment: 32
Number of tenants with cognitive impairment: 1
Total census: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory A. McClenahan | Chief Manager | Signed the Plan of Correction document dated 09-27-2024. |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 7
Jun 29, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to food service and safety practices at the assisted living facility.
Findings
The inspection found multiple deficiencies in food storage, labeling, and staff training on sanitation and safe food handling. Several food items were improperly labeled or stored, and most staff lacked required training on food safety.
Complaint Details
Complaint #113153-C was investigated, and regulatory insufficiencies were cited related to food service standards and safe food handling practices.
Deficiencies (7)
| Description |
|---|
| Eggs and cheese stored in the refrigerator were not labeled with the name of the item and date opened/prepared. |
| Packaged hamburger was stored in a container filled with water in the sink. |
| Freezer had boxes of food stored on the floor and unboxed items were not labeled to identify the item. |
| Walk-in refrigerator had raw hamburger stored on top of sour cream, butter, and fresh produce. |
| Staff failed to label food and raw meat was stored above other food. |
| Staff failed to follow proper food storage and handling as confirmed by the Administrator. |
| Personnel responsible for food preparation/service lacked orientation on sanitation and safe food handling and annual in-service training (5 of 7 staff reviewed). |
Report Facts
Number of tenants without cognitive impairment: 42
Number of tenants with cognitive impairment: 0
Staff lacking training on sanitation and safe food handling: 5
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 0
Sep 19, 2022
Visit Reason
Investigation of complaints #101436-C and #107722-C at the assisted living facility.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints.
Complaint Details
Investigation of complaints #101436-C and #107722-C found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorders: 46
Number of tenants with cognitive disorders: 0
Total tenants: 46
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Dec 16, 2021
Visit Reason
The inspection was conducted to investigate complaints #98606, #99148, #98597, #98810, and #100379 and to perform an infection control review.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints or the infection control review.
Complaint Details
Complaints #98606, #99148, #98597, #98810, and #100379 were investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorders: 42
Number of tenants with cognitive disorders: 0
Total tenants: 42
Inspection Report
Renewal
Census: 41
Deficiencies: 0
May 12, 2021
Visit Reason
A recertification visit was conducted to determine compliance with certification for an Assisted Living Program. An onsite infection control survey was also completed.
Findings
There were no regulatory insufficiencies cited during the recertification and infection control survey.
Report Facts
Number of tenants without cognitive disorder: 41
Number of tenants with cognitive disorder: 0
Total census: 41
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 0
Dec 21, 2020
Visit Reason
The inspection was conducted as an investigation of complaints #90377-C, #91294-C, and #92300-C, as well as an onsite infection control survey.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints or the onsite infection control survey.
Complaint Details
Investigation of complaints #90377-C, #91294-C, and #92300-C found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 45
Number of tenants with cognitive disorder: 0
Total population: 45
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Nov 27, 2019
Visit Reason
Investigation of Complaint #86711-C at the assisted living facility Rose of Ames.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Complaint Details
Complaint #86711-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 51
Number of tenants with cognitive disorder: 4
Total Population: 55
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 0
Jul 30, 2019
Visit Reason
Investigation of complaint #84128-C at the assisted living facility Rose of Ames.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Complaint Details
Complaint #84128-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 49
Number of tenants with cognitive disorder: 1
Total Population of Program at time of on-site: 50
Inspection Report
Renewal
Census: 55
Deficiencies: 2
May 21, 2019
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for an Assisted Living Program.
Findings
The program failed to provide adequate treatment and services affecting all 55 tenants, including serving green discolored liver that tenants refused to eat, and failed to ensure approval from the Department of Human Services prior to hiring two staff with criminal histories.
Deficiencies (2)
| Description |
|---|
| Failure to provide adequate treatment and services as evidenced by serving green discolored liver that tenants refused to eat. |
| Failure to ensure approval from the Department of Human Services prior to hiring two staff with criminal histories. |
Report Facts
Number of tenants without cognitive disorder: 55
Number of tenants with cognitive disorder: 0
Total population of program at time of on-site: 55
Date survey completed: May 22, 2019
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Mar 26, 2019
Visit Reason
The inspection was conducted to investigate Complaints #81957-C and 81984-C at the assisted living facility.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints.
Complaint Details
Investigation of Complaints #81957-C and 81984-C found no regulatory insufficiencies.
Report Facts
Number of tenants with cognitive disorder: 55
Number of tenants without cognitive disorder: 0
Total census: 55
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Dec 24, 2018
Visit Reason
Investigation of Incident #79899-I at the assisted living program.
Findings
No regulatory insufficiencies were cited during the investigation.
Complaint Details
Investigation of Incident #79899-I found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 55
Number of tenants with cognitive disorder: 0
Total Population of Program: 55
Inspection Report
Renewal
Census: 51
Deficiencies: 0
May 17, 2017
Visit Reason
Recertification conducted to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification inspection for the Assisted Living Program.
Report Facts
Number of tenants without cognitive disorder: 51
Number of tenants with cognitive disorder: 0
Total population of program at time of on-site: 51
Total census of Assisted Living Program: 51
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Oct 17, 2016
Visit Reason
Investigation of complaints #62140-C and #62225-C at the assisted living program Rose of Ames.
Findings
No regulatory insufficiencies were cited during the complaint investigation at the assisted living program.
Complaint Details
Investigation of Complaint #62140-C and #62225-C found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 48
Number of tenants with cognitive disorder: 0
Total Population of Program at time of on-site: 48
Total census of Assisted Living Program: 48
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 2
Sep 21, 2015
Visit Reason
The inspection was conducted as a Final Complaint/Incident Investigation following a complaint/incident involving Tenant #1 at the Rose of Ames assisted living program.
Findings
The investigation found regulatory insufficiencies related to the evaluation of Tenant #1 after a suicide attempt and the failure to update the tenant's service plan to reflect changes in condition. Tenant #1 was not evaluated upon return to the program following the incident, and the service plan was not updated accordingly.
Complaint Details
The complaint investigation was substantiated with findings that Tenant #1 was not properly evaluated after a suicide attempt and the service plan was not updated to reflect the tenant's changed condition.
Deficiencies (2)
| Description |
|---|
| Evaluation of Tenant - The program failed to evaluate Tenant #1 within 30 days of occupancy and significant change, specifically after a suicide attempt. |
| Service Plans - The service plan for Tenant #1 was not updated following a suicide attempt to meet the tenant's specific service needs. |
Report Facts
Number of tenants without cognitive disorder: 58
Number of tenants with cognitive disorder: 0
Total census: 58
Date survey completed: Sep 29, 2015
Date of tenant's suicide attempt: Jul 17, 2015
Date of inspection visits: Sep 21, 2015
Date of inspection visits: Sep 29, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Signed letter regarding the Final Complaint/Incident Investigation Report |
Inspection Report
Monitoring
Census: 55
Deficiencies: 0
May 21, 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 review of recertification documents and related inspections was completed and accepted.
Report Facts
Number of tenants: 55
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 0
Feb 18, 2013
Visit Reason
The inspection was conducted as a final complaint/incident investigation following allegations related to tenant deaths, medication setup errors, and staffing issues at Rose of Ames Assisted Living.
Findings
The investigation found no regulatory insufficiency related to the death of Tenant #1 and no suicidal ideation substantiated. Medication planners for some tenants were reviewed with some discrepancies noted, but no regulatory insufficiency was cited for medication administration. Staffing allegations were investigated with no regulatory insufficiency noted.
Complaint Details
The complaint involved three main allegations: the death of Tenant #1 possibly by suicide, incorrect medication setup for 14 tenants, and understaffing including inability to respond to emergencies and staff sleeping on duty. The investigation found no regulatory insufficiency related to the death or staffing. Medication planners had some missing or extra pills but were filled by home health care managers. No regulatory insufficiency was cited for medications administered traditionally.
Report Facts
Number of tenants without cognitive disorder: 52
Number of tenants with cognitive disorder: 1
Total census: 53
Tenants identified for medication review: 14
Tenants whose planners were reviewed: 5
Inspection Report
Monitoring
Census: 55
Deficiencies: 2
Dec 19, 2012
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review the Plan of Correction in response to a Preliminary Recertification Monitoring Evaluation Report for the Rose of Ames Assisted Living facility.
Findings
The report found that the program did not receive any regulatory insufficiencies during the certification period. The Plan of Correction was accepted by the Department of Inspections and Appeals after review. Tenant service plans had some documentation issues, including missing tenant signatures and incomplete evaluations.
Deficiencies (2)
| Description |
|---|
| Service plan did not include Tenant #1's signature and was not based on evaluations. |
| Service plan for Tenant #2 was not signed by the tenant and was not based on evaluations. |
Report Facts
Total census: 55
Tenant meeting attendance: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephen King | Administrator | Administrator of The Rose of Ames Assisted Living |
| Lori Miner | RN BSN | Monitor conducting the evaluation visit |
| Rose Boccella | Program Coordinator | Signed the cover letter regarding the Final Recertification Monitoring Evaluation Report |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 6
Dec 20, 2011
Visit Reason
The inspection was conducted as a final complaint/incident investigation following reports of tenant falls and injuries at the Rose of Ames Assisted Living Program.
Findings
The investigation found that the program did not follow its own managed risk agreement related to tenant falls, and there were multiple incidents of tenants sustaining fractures from falls. Several regulatory insufficiencies were noted, including failure to follow policies and procedures, lack of staff training on fall procedures, insufficient staffing, and inadequate service plans.
Complaint Details
The complaint investigation was initiated due to multiple incidents of tenant falls resulting in fractures. Tenant #1 fell multiple times in a week, sustaining fractured ribs. Tenant #2 and Tenant #3 also sustained fractures from falls. The investigation included review of incident reports, monitoring observations, and staff interviews. The complaint was substantiated with findings of regulatory insufficiencies.
Deficiencies (6)
| Description |
|---|
| Program did not follow its procedure as outlined in the managed risk agreement with Tenant #1 who sustained more than one fall in a week. |
| Program policies and procedures did not meet minimum standards for incident reporting including allegations of dependent adult abuse. |
| All programs employing a new delegating nurse after January 1, 2010, did not provide documentation of required training related to Iowa rules and laws on assisted living. |
| Program did not provide documentation of training to dietary staff on fall procedures; dietary staff was not trained to assist tenants after falls. |
| A sufficient number of trained staff were not available at all times to fully meet tenants' identified needs. |
| The service plan did not meet the identified needs of Tenant #1 and was not individualized to indicate tenant's needs and preferences for assistance. |
Report Facts
Total census: 55
Number of tenants without cognitive disorder: 55
Number of tenants with cognitive disorder: 0
Date of complaint/incident investigation: Dec 20, 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lori Miner | RN BSN | Monitor conducting the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Apr 25, 2011
Visit Reason
A complaint investigation was conducted at Rose of Ames on April 25, 2011, related to allegations of bed bugs and mold presence in the facility.
Findings
No regulatory insufficiencies were found during the evaluation. Pest control inspections revealed no bed bugs, and maintenance staff reported no mold problems in the building. Records showed regular cleaning and replacement of window air conditioners.
Complaint Details
Complaint Allegation #29677-C involved allegations of bed bugs and mold odor possibly emanating from a green wall. Investigations found no bed bugs or mold present. Pest control records and maintenance reports supported these findings. Regulatory insufficiency was not noted.
Report Facts
Current number of tenants without cognitive disorder: 59
Current number of tenants with cognitive disorder: 0
Total Population: 59
Number of tenants at community meeting: 32
Number of tenant rooms inspected: 58
Number of window air conditioners replaced or exchanged in 2010: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 0
Jun 24, 2010
Visit Reason
The inspection was conducted as a final complaint investigation triggered by allegations of bed bugs at Rose of Ames Assisted Living.
Findings
No regulatory insufficiencies were identified during the investigation. The pest control company treated the tenant's apartment for bed bugs, and no other infestations were found in adjacent apartments.
Complaint Details
The complaint alleged bed bugs at the program. Tenant #1 reported small bites and bed bugs were found on the tenant's comforter. Pest control treated the apartment and follow-up inspections found no further infestations. Other tenants reported no bed bug problems. No regulatory insufficiency was noted.
Report Facts
Current number of tenants without cognitive disorder: 60
Current number of tenants with cognitive disorder: 0
Total Population: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor who conducted the complaint investigation |
| Connie Schaffer | Certification Coordinator - Central/Eastern Iowa | Signed the cover letter transmitting the report |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 0
May 1, 2009
Visit Reason
The inspection was conducted as a complaint investigation regarding allegations about a tenant who left skilled care and returned to their apartment against medical advice, with concerns about the apartment's condition and tenant's compliance with care.
Findings
The investigation found no regulatory insufficiencies. The tenant was admitted with multiple sclerosis and depression, had multiple falls, and the apartment was in an unsanitary condition. The tenant refused services and access to the social worker. The program issued an eviction notice and the tenant was in the process of moving out.
Complaint Details
Complaint Allegation: Tenant left skilled care and returned to apartment against medical advice; apartment contained garbage and boxes making walking difficult; tenant refused services and social worker access; tenant noncompliant with personal care. Monitoring observations confirmed tenant's health issues and unsafe environment. No regulatory insufficiencies were noted.
Report Facts
Current number of tenants without cognitive disorder: 57
Current number of tenants with cognitive disorder: 0
Total Population: 57
Date of Investigation: May 1, 2009
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vickie G. Clingan | RN, MA | Monitor conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 0
Mar 16, 2009
Visit Reason
A complaint investigation was conducted at Rose of Ames related to allegations of increased fees without reasonable explanation for the mandatory fee except hiring a licensed social worker.
Findings
The investigation found that tenants were given proper notice of the fee increase and meetings were held to explain the rate increases and services. No regulatory insufficiencies were identified.
Complaint Details
Complaint 22374-C alleged the program had increased fees with no reasonable explanation for the mandatory fee except hiring a licensed social worker. The complaint was not substantiated as documentation and tenant interviews showed compliance with notification requirements.
Report Facts
Current number of tenants without cognitive disorder: 58
Current number of tenants with cognitive disorder: 0
Total Population: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Streepy | RN | Monitor conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 0
Dec 8, 2006
Visit Reason
The visit was conducted as a recertification monitoring evaluation and complaint investigation following a complaint alleging the program admitted and retained tenants requiring a higher level of care than appropriate for assisted living.
Findings
The investigation found no regulatory insufficiencies. Tenant #1 had been discharged and was deceased. Tenant #2 was independent with transfers and toileting despite significant health issues. Allegations that family members stay for extended periods and that staff neglect more functional tenants were refuted by tenant and staff reports.
Complaint Details
Complaint alleged the program admitted and retained tenants requiring a higher level of care than appropriate, including Tenant #1 (discharged and deceased) and Tenant #2 (with multiple health issues). It was also alleged family members stay for extended periods to provide care and staff neglect more functional tenants. The complaint was not substantiated.
Report Facts
Current number of tenants without cognitive disorder: 58
Current number of tenants with cognitive disorder: 0
Total Population: 58
Admission date of Tenant #2: May 20, 2005
Date of nursing notes for Tenant #2: Nov 11, 2006
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LuAnn Williams | Lutheran Community Services RN | Interviewed by monitors regarding tenant status and care |
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