Inspection Reports for The Willows of Marshalltown
2315 Campbell Dr, Marshalltown, IA 50158, United States, IA, 50158
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Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 1
May 6, 2025
Visit Reason
The inspection was conducted as an investigation of Incident #124236-I related to tenant rights and care concerns at the assisted living facility.
Findings
The investigation found that the facility failed to provide adequate care, treatment, and services to Tenant #1, who suffered a fall resulting in a fractured pelvis. The facility lacked a formal protocol to ensure chair alarms were properly functional at all times.
Complaint Details
Investigation of Incident #124236-I found regulatory insufficiencies related to tenant rights and care. Incident #124235-I had no regulatory insufficiencies cited.
Deficiencies (1)
| Description |
|---|
| Failure to provide adequate care, treatment, and services to Tenant #1, including lack of proper functioning chair alarms and insufficient staff assistance. |
Report Facts
Number of tenants without cognitive impairment: 2
Number of tenants with cognitive impairment: 28
Total census: 30
Date of incident: 101924
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 11
Sep 26, 2024
Visit Reason
The inspection was conducted related to the investigation of Complaint #120431-C, several incidents, and the recertification visit to determine compliance with certification of a Dedicated Dementia Specific Assisted Living Program.
Findings
The facility was cited for multiple regulatory insufficiencies including failure to follow established policies and procedures related to incident reports and medication administration, failure to notify the Department of major injuries within required timeframes, failure to complete evaluations within 30 days of occupancy, failure to discharge tenants requiring two-person assistance, failure to maintain proper documentation including nurse notes and advance directives, failure to update service plans as needed, and failure to have a licensed dietitian responsible for therapeutic diets.
Complaint Details
The complaint investigation was triggered by Complaint #120431-C and related incidents involving medication administration errors, falls with injury, and failure to follow policies and procedures.
Deficiencies (11)
| Description |
|---|
| Failed to follow established policies and procedures related to incident reports and administration of as needed medications. |
| Failed to notify the Department of accidents causing major injuries within 24 hours or next business day. |
| Failed to complete tenant evaluations within 30 days of occupancy. |
| Failed to discharge tenants requiring routine two-person assistance with transfers and ambulation. |
| Failed to document nurse's notes by exception for several tenants. |
| Failed to maintain advance health care directives for a tenant who had a fall and died. |
| Failed to maintain task sheets for a tenant unable to advocate for self with multiple service providers. |
| Failed to maintain nurse communication documents and 24 hour reports. |
| Failed to update service plans as tenant needs changed. |
| Failed to have a licensed dietitian responsible for reviewing food preparation and service for therapeutic diets. |
| Failed to maintain proper documentation of life safety door alarm system functionality and testing. |
Report Facts
Census: 27
Tenants with cognitive impairment: 25
Tenants without cognitive impairment: 2
Deficiency counts: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stanley | Executive Director | Named in relation to incident reporting and notification failures |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 3
Dec 29, 2022
Visit Reason
The inspection was conducted as an investigation of Complaint #107449-C regarding regulatory insufficiencies at the facility.
Findings
The facility failed to ensure tenants did not exceed their level of care, specifically for one tenant requiring two-person assistance for transfers. Additionally, the facility failed to discharge a tenant with unmanageable verbal and physical aggression and failed to update service plans to reflect tenants' needs and use of PRN medications for behavior management.
Complaint Details
Investigation of Complaint #107449-C revealed issues with tenant care levels, management of aggressive behavior, and service plan updates.
Deficiencies (3)
| Description |
|---|
| Failed to ensure tenants did not exceed level of care for 1 of 2 tenants reviewed who required two-person assistance for transfers. |
| Failed to discharge a tenant displaying unmanageable verbal and physical aggression. |
| Failed to update service plans based on tenant's identified needs and preferences, including use of PRN medication for managing aggression. |
Report Facts
Number of tenants without cognitive disorder: 5
Number of tenants with cognitive disorder: 22
Total census: 27
PRN medication administrations for aggression in August 2022: 5
PRN medication administrations for aggression in September 2022: 7
PRN medication administrations for aggression in October 2022: 10
PRN medication administrations for aggression in November 2022: 21
PRN medication administrations for aggression in December 2022: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stanley | Author of the Plan of Correction memo |
Inspection Report
Renewal
Census: 24
Deficiencies: 12
Aug 12, 2021
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the onsite infection control survey or complaint investigations. However, several regulatory insufficiencies were cited during the recertification visit related to record checks, tenant evaluations, service plans, nurse reviews, food service training, and dementia-specific education for personnel.
Deficiencies (12)
| Description |
|---|
| Failed to complete criminal, child, and dependent adult abuse background checks prior to employment for 1 of 8 staff reviewed. |
| Failed to submit an evaluation to the Department of Human Services for 2 of 2 staff with a criminal history. |
| Failed to evaluate each tenant's functional, cognitive, and health status within 30 days of occupancy for 3 of 4 tenants reviewed. |
| Failed to evaluate functional, cognitive, and health status as needed for significant change for 2 of 4 tenants reviewed. |
| Failed to meet criteria for admission/retention for tenants requiring routine two-person assistance with standing, transfer, or evacuation. |
| Failed to update service plans within 30 days of occupancy and as needed with significant change for 3 of 4 tenants reviewed. |
| Failed to update service plans to include outside service providers for 2 of 4 tenants reviewed. |
| Failed to ensure comprehensive nurse reviews every 90 days or as needed for 2 of 4 tenants reviewed. |
| Failed to provide annual in-service training on food protection for 2 of 7 staff who handled food. |
| Failed to provide 8 hours of dementia-specific education within 30 days of employment for 8 of 8 staff reviewed. |
| Failed to provide annual dementia-specific continuing education for 2 of 8 staff reviewed. |
| Failed to provide hands-on dementia training within 30 days of employment for 8 of 8 staff reviewed. |
Report Facts
Number of tenants without cognitive disorder: 2
Number of tenants with cognitive disorder: 22
Total census: 24
Staff reviewed for background checks: 8
Tenants reviewed for evaluations and service plans: 4
Staff reviewed for food protection training: 7
Staff reviewed for dementia-specific education: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Failed background checks prior to employment | |
| Staff A | Criminal history and evaluation issues, dementia training deficiencies | |
| Staff G | Criminal history and evaluation issues, dementia training deficiencies | |
| Staff B | Dementia training deficiencies | |
| Staff C | Dementia training deficiencies | |
| Staff D | Dementia training deficiencies | |
| Staff E | Failed food protection training and dementia training deficiencies | |
| Staff H | Dementia training deficiencies |
Inspection Report
Routine
Census: 23
Deficiencies: 0
Jul 21, 2020
Visit Reason
The inspection was conducted as an onsite infection control survey for the assisted living program serving people with dementia.
Findings
There were no deficiencies cited during the onsite infection control survey completed on 2020-07-21.
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 2
Oct 28, 2019
Visit Reason
The inspection was conducted as an investigation of Complaint #86455-C regarding regulatory insufficiencies at the Willows of Marshalltown Assisted Living Program for People with Dementia.
Findings
The program failed to develop individualized service plans based on identified needs and preferences for assistance for 2 of 3 tenants reviewed. Additionally, the program failed to document and assess the health status of tenants adequately, including falls and related interventions.
Complaint Details
Complaint #86455-C was investigated, focusing on service plans and nurse reviews related to tenant falls and assistance needs. Findings confirmed failures in individualized service planning and health status documentation.
Deficiencies (2)
| Description |
|---|
| Failed to develop individualized service plans based on identified needs and preferences for assistance for 2 of 3 tenants reviewed. |
| Failed to document and assess the health status of 2 of 3 tenants reviewed, including falls and ensure appropriate interventions. |
Report Facts
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 17
Total census: 18
Morse Fall assessment score: 75
Morse Fall assessment score: 65
Number of falls: 9
Inspection Report
Original Licensing
Census: 11
Deficiencies: 9
Dec 6, 2018
Visit Reason
The inspection was conducted as an initial visit to determine compliance with certification rules for an Assisted Living Program for People with Dementia.
Findings
The program failed to complete required cognitive evaluations prior to admission for 2 of 4 tenants reviewed, failed to complete comprehensive assessments within 30 days for 4 of 4 tenants, and failed to develop service plans based on required assessments. Additional deficiencies included failure to obtain signatures on service plans, failure to update service plans with significant changes, failure to include outside providers on service plans, failure to include planned activities based on personal interests, and failure to provide required dementia-specific education and training for staff.
Deficiencies (9)
| Description |
|---|
| Program failed to complete cognitive evaluations prior to admission for 2 of 4 tenants reviewed. |
| Program failed to complete comprehensive assessments within 30 days or with significant change for 4 of 4 tenants reviewed. |
| Program failed to develop service plans based on required evaluations for 4 of 4 tenants reviewed. |
| Program failed to obtain signatures from all parties who developed the service plan prior to occupancy for 2 of 4 tenants reviewed. |
| Program failed to update service plans as required for 1 tenant with significant change. |
| Program failed to include outside providers on the service plan for 1 tenant receiving hospice services. |
| Program failed to include a list of planned and spontaneous activities based on personal interests in service plans for 4 of 4 tenants reviewed. |
| Program failed to provide 8 hours of dementia-specific training within 30 days of employment for 14 of 16 staff reviewed. |
| Program failed to provide documentation of hands-on dementia training for 14 of 16 staff reviewed. |
Report Facts
Number of tenants without cognitive disorder: 3
Number of tenants with cognitive disorder: 8
Total census: 11
Staff reviewed for dementia training: 16
Staff lacking dementia training within 30 days: 14
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