Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Aug 21, 2025
Visit Reason
Investigation of Complaint #128262-C at Vintage Hills Retirement Community AL.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Complaint Details
Complaint #128262-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive impairment: 41
Number of tenants with cognitive impairment: 0
Total census: 41
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 3
Feb 3, 2025
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #126012-C, while other complaints (#124196-C, #124388-C, and #126244-C) were also reviewed but found without regulatory insufficiencies.
Findings
The investigation found that the program failed to ensure staff followed the established policy for documenting resident occurrences via RN Communication Forms, failed to document nurse's notes by exception, and failed to complete nurse reviews with changes in health status for one tenant (Tenant C1).
Complaint Details
The complaint investigation focused on Tenant C1, who exhibited worsening health symptoms over several days in January 2025. Staff failed to complete RN Communication Forms to relay concerns, and nurse reviews were not conducted despite significant changes in health status. The tenant was found unresponsive and not breathing on 1/13/25. The investigation substantiated failures in policy adherence and documentation.
Deficiencies (3)
| Description |
|---|
| Failure to ensure staff followed the established policy titled 'Other Resident Occurrences' requiring use of RN Communication Forms for documenting changes in tenant health status. |
| Failure to document all nurse's notes by exception for Tenant C1. |
| Failure to ensure nurse reviews were completed with changes in health status for Tenant C1. |
Report Facts
Number of tenants without cognitive impairment: 32
Number of tenants with cognitive impairment: 0
Total census: 32
Dates of staff failure to complete RN Communication Forms: 9
Compliance Date: Mar 15, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Reported Tenant C1's worsening condition and failure to complete RN Communication Forms | |
| Staff B | Observed Tenant C1's symptoms and failure to complete RN Communication Forms | |
| Staff D | Worked with Tenant C1 and failed to complete RN Communication Forms | |
| Staff F | Observed Tenant C1's condition and failed to complete RN Communication Forms | |
| Staff I | Observed Tenant C1's condition and failed to complete RN Communication Forms | |
| Healthcare Coordinator | HCC | Failed to document nurse's notes by exception and nurse reviews; received education and completed late entry documentation |
| Community Director | Confirmed staff failures and responsible for compliance oversight | |
| Triage Nurse 1 | On call during weekend of 1/11/25 and 1/12/25; did not complete nurse review in person |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 2
Aug 29, 2024
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program and to investigate multiple complaints, including Complaint #121622-C.
Findings
No regulatory insufficiencies were found during the recertification or investigation of several complaints, but regulatory insufficiencies were cited during the investigation of Complaint #121622-C related to medication administration and service plan deficiencies for one former tenant (Tenant C1).
Complaint Details
The investigation was related to Complaint #121622-C. The findings were substantiated as the program failed to administer medications as prescribed and failed to include tenant preferences in the service plan for Tenant C1.
Deficiencies (2)
| Description |
|---|
| The program failed to ensure medications were administered as prescribed for Tenant C1, including discrepancies in medication orders and administration of Escitalopram, Clonazepam, and Lorazepam without proper physician orders. |
| The program failed to include all tenant preferences in the service plan for Tenant C1, specifically lacking guidance to notify the tenant's family prior to any medication changes. |
Report Facts
Total census: 31
Number of tenants without cognitive impairment: 31
Number of tenants with cognitive impairment: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Healthcare Coordinator | Confirmed lack of medication orders and service plan deficiencies related to Tenant C1 | |
| Community Director | Confirmed findings related to medication administration and service plan deficiencies for Tenant C1 | |
| On-Call Registered Nurse | Administered medication discontinuation orders and failed to notify family as required |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 0
Jun 26, 2023
Visit Reason
Investigation of Complaints #108865-C and 110180-C at Vintage Hills Retirement Community Assisted Living.
Findings
No regulatory insufficiencies were cited during the complaint investigations.
Complaint Details
Investigation of Complaints #108865-C and 110180-C found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive impairment: 28
Number of tenants with cognitive impairment: 2
Total census: 30
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 1
Sep 27, 2022
Visit Reason
The inspection was conducted to investigate multiple complaints (#106641-C, 106640-C, 106992-C, and 107861-C) and to conduct a recertification visit to determine compliance with certification of an Assisted Living Program.
Findings
The program failed to consistently ensure all personnel, including contract/agency staff, were appropriately trained to meet tenant needs, specifically regarding medication administration. This affected all 36 tenants and specifically one tenant receiving morphine. No deficiencies were found related to Incident #105897-I.
Complaint Details
The investigation of complaints #106641-C, 106640-C, 106992-C, and 107861-C revealed training deficiencies for contract/agency staff. The program failed to provide training documentation for 6 of 6 contract/agency staff reviewed and failed to ensure all staff administering morphine to Tenant #1 had received appropriate training.
Deficiencies (1)
| Description |
|---|
| Failure to consistently ensure all personnel including contract/agency staff were appropriately trained to meet tenant needs, affecting medication administration. |
Report Facts
Number of tenants without cognitive impairment: 36
Number of tenants with cognitive impairment: 0
Total census: 36
Contract/agency staff without training documentation: 6
Agency staff worked since 8/1/22: 51
Morphine dose administered to Tenant #1: 0.25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Regional Assisted Living Director-Iowa | Interviewed and confirmed failure to ensure contract/agency staff received required training | |
| AL Health Specialist | Confirmed staff administering morphine and training deficiencies |
Inspection Report
Renewal
Census: 31
Deficiencies: 0
Oct 22, 2020
Visit Reason
The inspection was conducted as a recertification to determine compliance with certification for an Assisted Living Program and included an onsite infection control survey.
Findings
No regulatory insufficiencies were cited during the recertification and infection control survey.
Report Facts
Number of tenants without cognitive disorder: 26
Number of tenants with cognitive disorder: 5
Inspection Report
Renewal
Census: 27
Deficiencies: 0
Oct 29, 2018
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 for the Assisted Living Program.
Report Facts
Number of tenants without cognitive disorder: 25
Number of tenants with cognitive disorder: 2
Total Population of Program: 27
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