The most recent inspection on August 21, 2025, found no deficiencies during a complaint investigation. Earlier inspections showed a mixed pattern, with some deficiencies related to medication administration, nursing documentation, and staff training, particularly involving one tenant’s care and medication management. Inspectors cited failures to follow policies for documenting health changes, incomplete nurse reviews, medication errors, and insufficient training for contract staff administering medications. Complaint investigations were mostly unsubstantiated except for a few substantiated cases involving documentation and medication issues, including one tenant who experienced worsening health and was found unresponsive. The facility’s recent clean inspection suggests some improvement following earlier identified issues.
Deficiencies (last 6 years)
Deficiencies (over 6 years)1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
77% better than Iowa average
Iowa average: 4.4 deficiencies/year
Deficiencies per year
43210
2018
2020
2022
2023
2024
2025
Census
Latest occupancy rate41 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
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: 32Number of tenants with cognitive impairment: 0Total census: 32Dates of staff failure to complete RN Communication Forms: 9Compliance 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
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: 31Number of tenants without cognitive impairment: 31Number 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
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: 36Number of tenants with cognitive impairment: 0Total census: 36Contract/agency staff without training documentation: 6Agency staff worked since 8/1/22: 51Morphine 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
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: 26Number of tenants with cognitive disorder: 5