Inspection Reports for
Wellington Place
2475 River Road, Decorah, IA, 521017591
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
0.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
86% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
57% occupied
Based on a February 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Deficiencies: 0
Date: Aug 7, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction for Wellington Place nursing home, documenting the results of a regulatory survey completed on 08/07/2025.
Findings
No health deficiencies were found during the survey.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 16, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at Wellington Place nursing home.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Renewal
Census: 39
Deficiencies: 0
Date: Feb 1, 2024
Visit Reason
The visit was a recertification visit conducted to determine compliance with certification rules for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification visit.
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 2
Date: Aug 10, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a medication error where a resident did not receive a physician-ordered diuretic medication, resulting in harm.
Complaint Details
The complaint investigation found that Resident #42 did not receive the prescribed Lasix medication on 8/2/23 and 8/3/23 due to the pharmacy not receiving the faxed order. This medication error caused the resident to develop fluid overload and atrial fibrillation, requiring direct hospital admission. The nurse responsible was suspended and received education. The facility lacked a process to reconcile medication orders with pharmacy deliveries.
Findings
The facility failed to ensure medication orders were received from the pharmacy, resulting in Resident #42 not receiving Lasix as ordered for two days. This led to fluid overload and atrial fibrillation requiring hospital admission. The facility implemented education and competency training for nursing staff following the incident.
Deficiencies (2)
Failure to have a system in place to ensure medication orders were received from the pharmacy, resulting in a medication error and resident harm.
Failure to administer a diuretic medication as ordered, causing significant medication error and hospitalization.
Report Facts
Resident census: 44
Medication doses missed: 2
BNP lab value: 8313
Medication order duration: 4
Weight measurements: 185
Weight measurements: 193
Weight measurements: 197
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Registered Nurse | Nurse responsible for not administering Lasix medication on 8/2/23 and 8/3/23; received verbal warning and two-day suspension |
| Director of Nursing | Director of Nursing (DON) | Provided education and competency training to nursing staff; reported medication error and coordinated investigation |
| Staff H | Licensed Practical Nurse (LPN) | Reported holding Lasix medication on 8/4/23 and documented resident condition |
| ARNP | Advanced Registered Nurse Practitioner | Ordered Lasix medication and evaluated resident; reported medication not administered and resident condition |
| Staff I | Licensed Practical Nurse (LPN) | Documented resident's vital signs and condition |
| Staff J | Registered Nurse (RN) | Documented resident's symptoms and condition |
| Staff K | Registered Nurse (RN) | Reported resident's swelling and medication administration practices |
| Staff L | Licensed Practical Nurse (LPN) | Reported resident swelling and therapy involvement |
| Pharmacy Technician | Pharmacy Technician | Reported pharmacy did not receive medication order and communication issues with facility |
| Primary Physician | Physician | Reported hospitalization could have been prevented if medication had been administered |
| Regional Director of Operations | Regional Director of Operations | Provided education to DON on proper faxing procedures for medication orders |
| Administrator | Facility Administrator | Reported need for investigation and process improvements after medication error |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 3
Date: Aug 10, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a medication error where a physician ordered diuretic medication was not administered to Resident #42, resulting in harm and hospitalization.
Complaint Details
The complaint investigation revealed a medication error involving Resident #42 where Lasix was not administered on two consecutive days due to the medication not being received from the pharmacy. This resulted in resident harm requiring hospitalization. The facility reported the incident to the state agency and initiated a full investigation.
Findings
The facility failed to ensure medication orders were received from the pharmacy, resulting in Resident #42 not receiving prescribed Lasix medication on 8/2/23 and 8/3/23. This led to fluid overload and atrial fibrillation requiring hospital admission. The facility took corrective actions including education and competency checks for nursing staff.
Deficiencies (3)
Failure to administer physician ordered diuretic medication resulting in resident harm and hospitalization.
Failure to ensure medication orders were received from the pharmacy, causing medication delivery errors.
Failure to handle food plates and drinking glasses without touching food or drinking surfaces during meal service.
Report Facts
Resident census: 44
Medication doses missed: 2
BNP lab value: 8313
Resident weight: 197
Residents served meal: 39
Residents not served meal: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Registered Nurse | Nurse involved in medication error for Resident #42; received verbal warning and two-day suspension |
| Director of Nursing | Director of Nursing (DON) | Reported medication error, coordinated investigation and corrective actions |
| Staff H | Licensed Practical Nurse | Documented medication hold and resident condition; reported missing medication |
| ARNP | Advanced Registered Nurse Practitioner | Ordered Lasix for Resident #42 and assessed resident condition |
| Staff B | Certified Dietary Manager | Observed and confirmed improper handling of plates and glasses during meal service |
Inspection Report
Renewal
Census: 30
Deficiencies: 0
Date: Jun 29, 2021
Visit Reason
The inspection was conducted as a recertification to determine compliance with certification for an Assisted Living Program, including an investigation of a complaint and an onsite infection control survey.
Complaint Details
Complaint #98075-C was investigated and no regulatory insufficiencies were cited.
Findings
No regulatory insufficiencies were cited during the recertification, the complaint investigation, or the infection control survey.
Report Facts
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 2
Total census: 30
Inspection Report
Renewal
Census: 33
Deficiencies: 0
Date: Jun 18, 2019
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.
Inspection Report
Renewal
Census: 30
Deficiencies: 0
Date: Jun 22, 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.
Inspection Report
Monitoring
Census: 29
Deficiencies: 0
Date: Jun 16, 2015
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation to review recertification documents and compliance with Iowa Code and Administrative Code for Wellington Place Assisted Living in Decorah, IA.
Findings
No regulatory insufficiencies were found during the recertification evaluation. The review included acceptance of submitted documents, State Fire Marshal inspection report, and Facility Engineer's approval of evacuation plans.
Report Facts
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 1
Total population of Program at time of on-site: 29
Total census of Assisted Living Program: 29
Inspection Report
Monitoring
Census: 33
Deficiencies: 0
Date: Jan 8, 2013
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted by the Iowa Department of Inspections and Appeals to review recertification documents and perform an onsite monitoring evaluation of Wellington Place Assisted Living Program.
Findings
No regulatory insufficiencies were found during this onsite recertification monitoring evaluation. The program did not receive any regulatory insufficiencies during this recertification period.
Report Facts
Number of tenants without cognitive disorder: 32
Number of tenants with cognitive disorder: 1
Total Population of Program at time of on-site: 33
Total census of Assisted Living Program: 33
Community meeting tenants: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kris Thuente | RN Director | Director of Wellington Place Assisted Living Program |
| Margaret Kaltefleiter | RN MS | Monitor conducting the evaluation |
| Jim Berkley | Program Coordinator | Author of the cover letter for the report |
Inspection Report
Monitoring
Census: 18
Deficiencies: 0
Date: Feb 16, 2011
Visit Reason
An on-site monitoring evaluation was conducted at Wellington Place Assisted Living Program to assess compliance and regulatory sufficiency as part of a final recertification monitoring evaluation.
Findings
There were no regulatory insufficiencies noted during this certification period or during the on-site monitoring evaluation. Tenant satisfaction was positive, with tenants reporting respectful care and satisfaction with activities and food.
Report Facts
Current number of tenants without cognitive disorder: 16
Current number of tenants with cognitive disorder: 2
Total Population: 18
Tenants attending community meeting: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the on-site monitoring evaluation |
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