Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 2
Oct 15, 2024
Visit Reason
The inspection was conducted following the investigation of Incident #123945-I, Incident #123685-I, and Complaint #123922-C related to medication administration errors and narcotic discrepancies at Eagle Pointe Place Assisted Living.
Findings
The investigation found staff failed to follow established medication administration policies for multiple tenants, resulting in a medication error where Tenant #1 received Tenant #2's medications causing hospitalization. Additionally, discrepancies in narcotic medication counts were discovered, with evidence of medication destruction by staff to conceal errors. Staff involved were terminated and retraining and competency evaluations were implemented.
Complaint Details
The visit was complaint-related, investigating incidents and a complaint involving medication errors and narcotic discrepancies. The complaint was substantiated with findings of medication errors and improper narcotic handling.
Deficiencies (2)
| Description |
|---|
| Staff failed to follow the Program's established policies regarding medication administration for Tenant #1 and Tenant #2, resulting in Tenant #1 receiving Tenant #2's medications. |
| Staff failed to provide services in accordance with training for Tenant #3 and Tenant #4 regarding narcotic medication counts, including destruction of medication to conceal discrepancies. |
Report Facts
Total census: 89
Number of tenants without cognitive impairment: 85
Number of tenants with cognitive impairment: 4
Medication error incident date: Oct 8, 2024
Narcotic discrepancy date: Sep 16, 2024
Number of Lorezepam tablets counted first shift: 18
Number of Lorezepam tablets counted third shift: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in medication administration error involving Tenant #1 and Tenant #2 | |
| Staff E | Reported medication error and involved in medication administration incident | |
| Staff A | Involved in narcotic count discrepancy and medication destruction | |
| Staff B | Involved in narcotic count discrepancy | |
| Staff D | Medication manager who observed improper medication pass practices by Staff C | |
| Staff I | Witnessed Staff A destroying medication during narcotic count | |
| Executive Director | Executive Director | Confirmed findings and conducted staff retraining |
| Director of Health Services | Director of Health Services | Confirmed findings, conducted investigation, and retraining |
| Assistant Director of Health Services | Assistant Director of Health Services | Conducted investigation and interviews related to medication errors and narcotic discrepancies |
Inspection Report
Renewal
Census: 92
Deficiencies: 1
Jul 17, 2024
Visit Reason
The inspection was a recertification visit conducted to determine compliance with certification rules for an Assisted Living Program.
Findings
The program failed to develop individualized service plans that adequately addressed the needs of 5 of 9 tenants reviewed, specifically lacking clear specifications on the frequency of required frequent checks and dietary needs.
Deficiencies (1)
| Description |
|---|
| Failed to develop service plans to adequately address the needs of 5 of 9 tenants reviewed, including unclear frequency of frequent checks and missing dietary needs documentation. |
Report Facts
Number of tenants without cognitive impairment: 86
Number of tenants with cognitive impairment: 6
Total census: 92
Tenants reviewed for service plans: 9
Tenants with deficient service plans: 5
Resident charts audited per month: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN | Confirmed deficiencies in service plans regarding frequent checks and dietary needs | |
| Health Services Director (HSD) | Conducted chart audits and received education regarding documentation of resident individualized needs | |
| Assistant Health Service Director (AHSD) | Conducted chart audits and received education regarding documentation of resident individualized needs | |
| Executive Director (ED) | Responsible for quarterly audits to ensure service plans reflect specific requirements | |
| Director | Indicated unawareness of Tenant #3's dietary physician order |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 0
May 29, 2024
Visit Reason
The inspection was conducted as an investigation of Incident #120325-I and Complaints #118969-C and #121089-C.
Findings
No regulatory insufficiencies were cited during the investigation of the incident and complaints.
Complaint Details
Investigation of Incident #120325-I, Complaint #118969-C, and Complaint #121089-C found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive impairment: 82
Number of tenants with cognitive impairment: 8
Total census: 90
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 1
Jun 27, 2023
Visit Reason
The inspection was conducted as part of an investigation of Complaint #108982-C regarding regulatory compliance related to tenant records retention.
Findings
The program failed to retain all tenant records for a minimum of three years after transfer or death, specifically for one tenant whose records were destroyed after 90 days contrary to regulations.
Complaint Details
The visit was complaint-related, investigating Complaint #108982-C. The complaint was substantiated as the program did not retain tenant records for the required minimum of three years.
Deficiencies (1)
| Description |
|---|
| Failure to retain all records pertaining to the tenant for a minimum of three years after the transfer or death of the tenant. |
Report Facts
Total census: 85
Tenants without cognitive impairment: 82
Tenants with cognitive impairment: 3
Retention period for task sheets: 90
Corrective action completion date: Jun 27, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Care Services Manager | Interviewed and confirmed destruction of task sheets every 90 days | |
| Administrator | Confirmed not all tenant records were retained for minimum three years | |
| Director of Nursing | Made aware of correct record retention procedures and involved in training | |
| Assistant Director of Nursing | Trained on correct procedure for tenant records retention | |
| Former Regional Operations Manager | Informed staff that task sheets should be kept for 90 days then destroyed |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 1
Oct 12, 2022
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #105277-C and #100126-I, and to revisit and determine progress toward correcting deficiencies identified during investigations of Mandatory Reports #97518-M and #97371-M.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints. However, a regulatory insufficiency was re-cited for failure to complete Department of Human Services (DHS) evaluations for 5 staff members with criminal histories. The Director confirmed DHS evaluations were not initiated due to lack of training but committed to immediate action.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #105277-C & 100126-I. The deficiency cited was a re-citation from previous mandatory reports.
Deficiencies (1)
| Description |
|---|
| Failure to complete an evaluation by the Department of Human Services (DHS) for 5 staff members with criminal history prior to employment. |
Report Facts
Number of tenants without cognitive impairment: 78
Number of tenants with cognitive impairment: 2
Total census: 80
Number of staff with missing DHS evaluations: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in deficiency for missing DHS evaluation | |
| Staff B | Named in deficiency for missing DHS evaluation | |
| Staff C | Named in deficiency for missing DHS evaluation | |
| Staff D | Named in deficiency for missing DHS evaluation | |
| Staff E | Named in deficiency for missing DHS evaluation | |
| Executive Director | Executive Director | Completed and submitted criminal history forms to DHS and conducted audits |
| Regional Executive Director | Regional Executive Director | Trained Executive Director and Administrative Specialist on hiring process |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 1
Aug 17, 2021
Visit Reason
The inspection was conducted as a result of investigations of Mandatory Reports #97518-M and #97371-M regarding regulatory insufficiencies.
Findings
The program failed to ensure that 2 of 2 staff hired through staffing agencies had background checks completed by the Single Contact Repository or by a combination of the Department of Public Safety and the Department of Human Services, as required.
Complaint Details
The visit was complaint-related based on investigations of Mandatory Report #97518-M and Mandatory Report #97371-M. The deficiency was substantiated by interviews and record reviews confirming the failure to ensure appropriate background checks for agency staff.
Deficiencies (1)
| Description |
|---|
| Failure to ensure background checks were completed using the Single Contact Repository or required combination for 2 staff hired through staffing agencies. |
Report Facts
Number of tenants without cognitive disorder: 53
Number of tenants with cognitive disorder: 4
Total census: 57
Staff with missing required background checks: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Named in finding for missing required background check | |
| Staff K | Named in finding for missing required background check | |
| Executive Director | Executive Director | Removed Staff I and Staff K from providing services until background checks were completed; involved in corrective actions and audits |
| Interim Director | Confirmed findings during interview | |
| Care Services Manager | Confirmed findings during interview | |
| RDCS | Provided re-education to Executive Director on required background checks |
Inspection Report
Renewal
Census: 57
Deficiencies: 2
Aug 2, 2021
Visit Reason
The inspection was a recertification conducted to determine compliance with certification for an Assisted Living Program, including an onsite infection control survey.
Findings
The facility was found deficient in staffing procedures related to emergency response for tenants with cognitive disorders and in maintaining buildings and grounds in a clean, safe, and sanitary condition. Specific issues included failure to follow written procedures for emergency pendant response and inadequate housekeeping services resulting in unclean tenant apartments and common areas.
Deficiencies (2)
| Description |
|---|
| Failed to follow a system, program, or written staff procedure to address the Program's response to the emergency needs of tenants with cognitive disorder. |
| Failed to ensure all buildings and grounds were kept well-maintained, clean, safe and sanitary, including stained apartment flooring, unclean garbage disposal closets, and inadequate housekeeping services. |
Report Facts
Number of tenants without cognitive disorder: 53
Number of tenants with cognitive disorder: 4
Total census: 57
Pendant call response time: 49084
Housekeeping audit frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Evaluated residents and determined no unmet needs; involved in re-education and monitoring of emergency response and housekeeping | |
| Regional Director of Care Services | Re-educated Care Service Manager on emergency response procedures | |
| Care Service Manager | Re-educated on emergency response procedures and housekeeping procedures | |
| Interim Director | Confirmed findings related to housekeeping and emergency response | |
| Staff A | Interviewed regarding pendant system and housekeeping duties | |
| Staff D | Interviewed regarding pendant call response and housekeeping duties | |
| Staff E | Interviewed regarding housekeeping staffing and tenant complaints | |
| Maintenance Technician | Conducted observational audit of building and grounds with Executive Director |
Inspection Report
Renewal
Census: 57
Deficiencies: 8
Aug 14, 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 complete required tenant evaluations within 30 days of occupancy and as needed with significant changes, failed to ensure staff competency and training within required timeframes, failed to update service plans timely, failed to consistently administer medications as prescribed, and failed to maintain a clean and sanitary environment. Multiple deficiencies were cited related to tenant evaluations, staffing, service plans, nurse reviews, food service, medications, and structural requirements.
Deficiencies (8)
| Description |
|---|
| Program failed to complete tenant evaluations within 30 days of occupancy and as needed with significant change. |
| Program failed to ensure newly hired registered nurse and staff were competent and trained within required timeframes. |
| Program failed to update service plans as needed and ensure service plans reflected tenant needs. |
| Program failed to complete nurse reviews every 90 days for tenants. |
| Program failed to provide orientation and training on sanitation and safe food handling for staff. |
| Program failed to consistently administer medications and document medication administration as prescribed. |
| Program failed to maintain a well-maintained, clean, safe and sanitary building and grounds. |
| Program failed to update service plans within 30 days of tenant occupancy and as needed with significant change. |
Report Facts
Census: 57
Tenants reviewed: 5
Tenants reviewed: 4
Community meeting attendance: 15
Staff on first shift: 3
Staff on first shift: 2
Residents for audit: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robbie Hinz | Executive Director | Signed Plan of Correction letter |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 3
May 8, 2018
Visit Reason
An investigation of Complaint #75141-C was completed to assess regulatory compliance related to tenant rights and care treatment at Eagle Pointe Place.
Findings
The program failed to provide adequate and appropriate care, treatment, and services to tenants, specifically tenants #2 and #4, including failures in medication administration documentation, oxygen therapy management, and service plan development.
Complaint Details
Complaint #75141-C was investigated. The complaint involved inadequate care and treatment for tenants, including oxygen therapy and medication administration issues. The complaint was substantiated based on findings.
Deficiencies (3)
| Description |
|---|
| Program failed to provide care, treatment and services that were adequate and appropriate for tenants #2 and #4. |
| Program failed to document medication administration on multiple dates for tenant #2. |
| Program failed to develop individualized service plans reflecting tenant needs for tenants #2, #3, and #4. |
Report Facts
Number of tenants without cognitive disorder: 40
Number of tenants with cognitive disorder: 7
Total census: 47
Number of tenants reviewed: 4
Number of tenants affected by deficient service plans: 3
Number of tenants affected by inadequate care: 2
Medication administration documentation failures: 45
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Feb 28, 2018
Visit Reason
Investigation of Incident #74219-I at the assisted living program.
Findings
No regulatory insufficiencies were cited during the investigation.
Complaint Details
Investigation of Incident #74219-I; no regulatory insufficiencies found.
Report Facts
Number of tenants without cognitive disorder: 38
Number of tenants with cognitive disorder: 6
Total census: 44
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 2
Jan 11, 2018
Visit Reason
Investigation of Complaint #70696-C regarding tenant care and service deficiencies at Eagle Pointe Place.
Findings
The program failed to provide adequate and appropriate care, treatment, and services for Tenant #2, including failure to update service plans and ensure proper medication administration and meal documentation. Tenant #2 experienced a fall and neglectful care was identified. Service plans for Tenants #2 and #3 were not updated as required.
Complaint Details
Complaint #70696-C was investigated. The complaint was substantiated as the program failed to provide adequate care and services to Tenant #2 and failed to update service plans for Tenants #2 and #3.
Deficiencies (2)
| Description |
|---|
| Failure to provide adequate and appropriate care, treatment and services for Tenant #2. |
| Failure to update service plans as needed and failure to develop service plans to identify specific needs of tenants #2 and #3. |
Report Facts
Number of tenants without cognitive disorder: 45
Number of tenants with cognitive disorder: 7
Total census: 52
Number of tenants reviewed: 3
Date survey completed: Jan 11, 2018
Inspection Report
Renewal
Census: 50
Deficiencies: 5
Jul 19, 2017
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for an assisted living program and included investigation of Complaint #68271-C.
Findings
The program failed to ensure sufficient trained staff were available to meet tenants' needs, failed to complete required background checks prior to employment for some staff, failed to document nurses' notes by exception for some tenants, failed to develop individualized service plans reflecting tenant needs, and failed to provide orientation and annual training on sanitation and safe food handling for staff responsible for food service.
Complaint Details
Investigation of Complaint #68271-C was completed and no regulatory insufficiencies were identified related to the complaint.
Deficiencies (5)
| Description |
|---|
| Staffing: insufficient number of trained staff available at all times to meet tenants' identified needs. |
| Record Checks: failed to complete background checks including dependent adult abuse and child abuse registries prior to employment for 2 of 7 staff reviewed. |
| Tenant Documents: failed to document nurses' notes written by exception for 2 of 7 tenants reviewed. |
| Service Plans: failed to develop individualized service plans reflecting tenants' identified needs and preferences for assistance for 2 of 5 tenants reviewed. |
| Food Service: failed to provide orientation on sanitation and safe food handling prior to handling food and annual in-service training for 7 of 7 staff responsible for food service. |
Report Facts
Census: 50
Tenants without cognitive disorder: 47
Tenants with cognitive disorder: 3
Community meeting tenants: 25
Staff reviewed for background checks: 7
Tenants reviewed for nurses' notes: 7
Tenants reviewed for service plans: 5
Staff responsible for food service: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lori Dyke | Interim Executive Director | Named in Plan of Correction and interview regarding background checks and staff training. |
| Sherry Geerdes | Care Services Manager | Named in Plan of Correction and interview regarding staff training and care duties. |
| Staff A | Resident Care Partner | Failed to have completed background checks prior to employment; involved in findings related to record checks. |
| Staff G | Resident Care Partner | Failed to have completed background checks prior to employment; involved in findings related to record checks. |
| Staff H | Completed background checks after employment; trained on new employee background checks. |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 0
Mar 22, 2016
Visit Reason
The inspection was conducted as a final complaint/incident investigation following allegations regarding tenant rights, admission/discharge practices, structure/life safety, and staffing at Eagle Pointe Place.
Findings
No regulatory insufficiencies were identified. All allegations including tenant rights violations, improper admission/discharge, structure/life safety concerns, and staffing issues were found to be not substantiated after review of tenant files, interviews, observations, and community meetings.
Complaint Details
The complaint involved allegations that kitchen staff were rude to tenants, a tenant was not assisted after a fall and was transferred against their will, feces and mold were found in the facility, and kitchen staff acted inappropriately. All allegations were investigated and found not substantiated.
Report Facts
Total census: 46
Number of tenants without cognitive disorder: 39
Number of tenants with cognitive disorder: 7
Number of tenants at community meetings: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Signed the report and provided contact information |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 1
Dec 8, 2015
Visit Reason
The inspection was conducted as a complaint/incident investigation related to level of care concerns at Eagle Pointe Place, following tenant file reviews, incident reports, policy reviews, and staff interviews.
Findings
The investigation found no substantiated concerns regarding level of care but identified a regulatory insufficiency related to staffing, specifically inadequate training for safely transporting tenants in wheelchairs on the bus, which resulted in a tenant injury. A $6,000 civil penalty was assessed.
Complaint Details
Allegation: Level of Care. Findings: Not substantiated. Review of two tenant files showed appropriate assessments. One tenant was injured when their wheelchair tipped over on the program's vehicle due to improper securing and lack of staff training.
Deficiencies (1)
| Description |
|---|
| Staffing: The program failed to have a sufficient number of trained staff available to fully meet tenants' identified needs, including proper training on securely transporting tenants in wheelchairs on the bus, leading to a tenant injury. |
Report Facts
Civil penalty amount: 6000
Reduced civil penalty amount: 3900
Census: 45
Number of tenants without cognitive disorder: 41
Number of tenants with cognitive disorder: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Megan Pedersen | Administrator / Executive Director | Named as recipient of demand letter and in Plan of Correction signature |
| Rose Boccella | Program Coordinator | Contact person for the Department of Inspections and Appeals and recipient of Plan of Correction |
| Jim Friberg | Bureau Chief, Adult Services Bureau | Signed the demand letter |
| Staff A | Staff involved in the incident transporting tenant in wheelchair and cited for lack of proper training | |
| Maintenance Director | Interviewed regarding training and securing wheelchair brackets on bus | |
| Health Care Coordinator (HCC) | Interviewed regarding tenant injury and training |
Inspection Report
Original Licensing
Census: 49
Deficiencies: 3
Jun 2, 2015
Visit Reason
The inspection was conducted as a Final Initial Certification Monitoring Evaluation and Incident Investigation for Eagle Pointe Place, Dubuque, IA, to determine compliance with Iowa Code and Administrative Code chapters, including investigation of Incident #52899.
Findings
The investigation found the incident to be unsubstantiated. Regulatory insufficiencies were noted in the evaluation of tenants and service plans, including failure to evaluate tenants within required timeframes and incomplete service plans. The program was found to be in regulatory compliance overall and certification will continue for two years.
Complaint Details
The allegation of supervision/safety related to Incident #52899 was investigated and found to be unsubstantiated.
Deficiencies (3)
| Description |
|---|
| Failed to evaluate 2 out of 4 tenants using a functional assessment tool in conjunction with health and cognitive assessment within 30 days of occupancy or significant change. |
| Failed to ensure a preliminary service plan was developed prior to tenant signing the occupancy agreement for 4 of 4 tenants reviewed. |
| Failed to include all assessed needs on the service plan for 1 out of 6 tenants reviewed. |
Report Facts
Number of tenants without cognitive disorder: 37
Number of tenants with cognitive disorder: 12
Total population of program at time of on-site: 49
Total census of Assisted Living Program: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Scott Rausch | Executive Director | Named in Plan of Correction response letter |
| Rose Boccella | Program Coordinator | Named as contact and author of initial certification monitoring evaluation report |
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