Inspection Reports for
Wellington Place
2475 River Road, Decorah, IA, 521017591
Back to Facility Profile2 Reports
Inspection Report — Feb 1, 2024
Renewal
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 — Jun 29, 2021
Renewal
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
4 CMS Surveys
Inspection Report — Aug 7, 2025
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 — Oct 16, 2024
Annual Inspection
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 — Aug 10, 2023
Complaint Investigation
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.
Violations (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
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 — Aug 10, 2023
Complaint Investigation
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.
Violations (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
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 |
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