Inspection Reports for Whispering Willow AL
601 Dawn Avenue, Fredericksburg, IA, 506301033
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 1, 2024, cited one deficiency related to staff not following established policies during two incidents involving tenant falls and abuse reporting. Earlier inspections showed a pattern of deficiencies primarily involving service plans, dementia-specific staff training, and tenant care, including medication administration and staffing levels. Complaint investigations have substantiated issues such as inadequate care, incomplete evaluations, and failure to meet tenant rights, though some complaints were found unsubstantiated. Enforcement actions included a $500 civil penalty in 2010 related to medication administration and record-keeping, with no license suspensions or immediate jeopardy findings listed in the available reports. The facility’s record shows ongoing challenges with compliance, but some recent inspections indicate efforts to address prior concerns.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
4.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
11% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
24 residents
Based on a July 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 1
Date: Jul 1, 2024
Visit Reason
The inspection was conducted to investigate complaints #118864-C and #117755-C, and to perform a recertification visit to determine compliance with certification rules for an Assisted Living Program for People with Dementia.
Complaint Details
The complaint investigations involved allegations of abuse and improper handling of tenant falls. Tenant #1 was observed being pushed down on the shoulders and yelled at by staff, with bruises noted. Tenant C1 was found on the floor with bruises and a rug burn, and staff failed to follow fall policy procedures. The Community Director confirmed the findings and reported disciplinary actions.
Findings
No regulatory insufficiencies were cited during the complaint investigations and recertification visit. However, one deficiency was cited related to program policies and procedures where staff failed to follow established policies during two separate incidents involving two tenants.
Deficiencies (1)
Staff failed to follow established policies during two separate incidents involving two tenants, including improper handling of tenant falls and abuse reporting.
Report Facts
Number of tenants without cognitive impairment: 8
Number of tenants with cognitive impairment: 16
Total census: 24
Inspection Report
Renewal
Census: 22
Deficiencies: 4
Date: Jun 23, 2022
Visit Reason
The inspection was a recertification visit conducted to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
The program failed to evaluate a tenant's functional, cognitive, and health status as warranted by a significant change of condition, failed to update service plans to meet identified needs, failed to reflect person-centered planned and spontaneous activities in service plans, and failed to provide required dementia-specific education within 30 days of employment for some staff.
Deficiencies (4)
Failed to evaluate a tenant's functional, cognitive, and health status as warranted by a significant change of condition for 1 of 1 tenants reviewed.
Failed to update service plans as warranted to meet the identified needs for 1 of 3 tenants reviewed.
Failed to reflect person-centered planned and spontaneous activities on the service plans for 3 of 3 tenants reviewed unable to plan their own activities.
Failed to provide 8 hours of dementia-specific education and training within 30 days of employment for 3 of 6 staff reviewed.
Report Facts
Census - tenants without cognitive disorder: 11
Census - tenants with cognitive disorder: 1
Census - tenants without cognitive disorder: 0
Census - tenants with cognitive disorder: 10
Total census: 22
Staff reviewed for dementia training: 6
Staff lacking required dementia training within 30 days: 3
Inspection Report
Routine
Deficiencies: 0
Date: Aug 27, 2020
Visit Reason
The onsite infection control survey was conducted to assess regulatory compliance related to infection control practices at Whispering Willow Assisted Living.
Findings
No regulatory insufficiencies were cited during the infection control survey completed on 08/27/2020.
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 13
Date: Aug 7, 2018
Visit Reason
The inspection was conducted to investigate Complaint #77620 and to perform a recertification visit to determine compliance with certification rules for a Dementia Specific Assisted Living Program.
Complaint Details
The complaint investigation was related to concerns about care and services for tenants with dementia, including medication errors and inadequate assistance. The complaint number is #77620. The findings substantiated failures in care and services.
Findings
The program failed to provide adequate care, treatment, and services for tenants with dementia, including medication administration errors, insufficient staffing, failure to follow admission and retention criteria, incomplete incident reports, and inadequate service plans. The facility corrected regulatory insufficiencies by specified dates in August and September 2018.
Deficiencies (13)
Failure to provide care, treatment and services that were adequate and appropriate, including medication administration errors and assistance with toileting.
Insufficient number of trained staff to meet tenants' identified needs.
Engagement in prohibited services by program staff serving as representative payees for tenants.
Failure to obtain approval from Department of Human Services prior to employment for one staff member.
Failure to follow criteria for admission and retention of tenants with unmanageable incontinence.
Failure to complete incident reports as needed for tenants.
Failure to develop and update service plans annually and as needed for tenants.
Failure to provide food safety training and orientation for staff responsible for food preparation.
Failure to provide dementia-specific education and training to staff within required timeframes.
Failure to provide appropriate activities for tenants in the dementia unit.
Failure to provide person-centered service plans and spontaneous activities for tenants.
Failure to provide dementia-specific training including hands-on training to all employees upon hire and annually.
Failure to have single-action lockable entrance doors on tenant apartments in the dementia unit.
Report Facts
Number of tenants: 22
Number of tenants without cognitive disorder: 10
Number of tenants with cognitive disorder: 12
Number of double occupancy dwelling units: 26
Number of tenants reviewed: 7
Number of tenants reviewed: 6
Number of staff reviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Named in medication administration errors and verbal warnings | |
| Staff B | Assisted with tenant care and toileting | |
| Staff F | Revealed staffing issues and tenant incontinence | |
| Staff C | Revealed exhaust fan issues and staffing concerns | |
| Staff E | Employment without DHS approval | |
| Nurse Manager | Held in-service trainings and monitored staff | |
| Manager | Confirmed findings and coordinated corrective actions | |
| Assistant Manager | Confirmed training and staffing findings | |
| Staff A | Failed to complete food safety training | |
| Staff H | Failed to complete food safety training | |
| Staff D | Failed to complete dementia-specific training |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 1
Date: Feb 7, 2018
Visit Reason
The inspection was conducted as part of an investigation of Complaint #73710-C regarding regulatory insufficiency related to service plans for tenants.
Complaint Details
The investigation was triggered by Complaint #73710-C. The deficiency was substantiated as the service plan failed to address Tenant #1's needs as documented by physician orders and observations.
Findings
The program failed to ensure service plans included identified needs for one tenant, including risks for falls, therapy services, hallucinations, refusal of care, and skin issues. The Nurse Manager acknowledged the service plan did not reflect the tenant's identified needs.
Deficiencies (1)
The service plan did not include identified needs and preferences for assistance for Tenant #1, including fall risk interventions, therapy services, hallucinations, refusal of care, inappropriate behaviors, and skin treatment needs.
Report Facts
Number of tenants without cognitive disorder: 9
Number of tenants with cognitive disorder: 4
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 8
Total census: 21
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 4
Date: Jan 25, 2018
Visit Reason
The inspection was conducted as a result of a complaint investigation (Complaint 72223-C) regarding regulatory insufficiencies in the Assisted Living Program for People with Dementia at Whispering Willow Assisted Living.
Complaint Details
The complaint investigation (72223-C) substantiated multiple regulatory insufficiencies related to tenant rights, evaluations, service plans, and staff training. The tenant involved exhibited behaviors such as frequent dressing/undressing, wandering, and exit seeking, which were not adequately addressed by the facility.
Findings
The facility was found to have multiple regulatory insufficiencies related to tenant rights, evaluation of tenants, service plans, and dementia-specific education for personnel. Specific issues included failure to treat tenants with consideration and respect, incomplete evaluations within required timeframes, inadequate service plans addressing tenant needs, and insufficient dementia training for staff.
Deficiencies (4)
Tenant rights not met; failure to ensure a tenant was treated with consideration, respect, and full recognition of personal dignity and autonomy.
Failure to complete comprehensive evaluation of tenant with significant change within 30 days.
Service plans did not address identified needs for assistance for one tenant.
Dementia-specific education for personnel not completed within required timeframe for 4 of 8 staff reviewed.
Report Facts
Number of tenants without cognitive disorder: 6
Number of tenants with cognitive disorder: 4
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 10
Total Census: 23
Staff reviewed for dementia training: 8
Staff completing dementia training: 4
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 4
Date: Jan 25, 2018
Visit Reason
The inspection was conducted as a complaint investigation related to regulatory insufficiencies at Whispering Willow Assisted Living, specifically concerning tenant rights and care for tenants with dementia.
Complaint Details
The investigation was triggered by Complaint 72223-C. The complaint involved concerns about tenant rights and care, including treatment of a tenant with dementia, failure to obtain family permission for clothing removal, and inadequate staff training.
Findings
The facility failed to ensure that tenants were treated with consideration, respect, and full recognition of personal dignity and autonomy. Deficiencies were found in tenant rights, evaluation of tenants with significant change, service plans, and dementia-specific education for personnel.
Deficiencies (4)
Tenant rights were not met as the program failed to ensure a tenant was treated with consideration, respect, and full recognition of personal dignity and autonomy.
The program failed to complete a comprehensive evaluation with significant change for a tenant within 30 days of occupancy.
The program failed to ensure identified needs were addressed in the service plan for a tenant.
The program failed to ensure staff received a minimum of eight hours of dementia-specific education and training within 30 days of employment.
Report Facts
Number of tenants without cognitive disorder: 6
Number of tenants with cognitive disorder: 4
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 10
Total Census: 23
Staff reviewed for dementia-specific education: 8
Staff not meeting dementia training requirements: 4
Inspection Report
Renewal
Census: 16
Deficiencies: 1
Date: Oct 12, 2016
Visit Reason
The inspection was conducted during the recertification to determine compliance with certification of an Assisted Living Program and a Complaint investigation 62900-C.
Findings
The program failed to consistently follow policies and procedures related to medication administration, including administration of expired medications and borrowing medications between tenants. Several medication errors and policy violations were documented.
Deficiencies (1)
Program failed to consistently follow policies and procedures related to medication administration affecting 3 of 5 tenants, including administration of expired medications and borrowing insulin from another tenant.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 8
Number of tenants with cognitive disorder in General Population Program: 2
Total Population of General Population Program: 10
Number of tenants without cognitive disorder in Dementia-Specific Program: 0
Number of tenants with cognitive disorder in Dementia-Specific Program: 6
Total Population of Dementia-Specific Program: 6
Total census of Assisted Living Program: 16
Medication/Treatment Error Reports: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administered medication errors and failed to follow medication administration policies | |
| Manager | Responsible for re-educating staff on medication administration policies and monitoring compliance | |
| RN | Registered Nurse | Involved in re-education and monitoring of medication administration policies |
| Nurse | Confirmed lack of system to monitor prescription expiration and acknowledged policy not followed | |
| Administrator | Acknowledged policy had not been followed during exit interview |
Inspection Report
Monitoring
Census: 23
Deficiencies: 3
Date: Sep 25, 2014
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation Report following a survey by the Department of Inspections and Appeals (DIA) to evaluate regulatory compliance in areas including Record Checks, Dementia-Specific Education for Program Personnel, and Other related requirements.
Findings
The report identified regulatory insufficiencies related to incomplete background checks for staff, lack of dementia-specific training for certain personnel, and inadequate orientation on sanitation and safe food handling for staff responsible for food preparation and service.
Deficiencies (3)
Staff #4's personnel file did not reveal a second background check prior to rehire as required.
Staff #5 had not received any dementia-specific training as required within 30 days of employment or contract.
Staff responsible for food preparation and service did not receive orientation on sanitation and safe food handling prior to handling food.
Report Facts
General Population Program tenants without cognitive disorder: 12
General Population Program tenants with cognitive disorder: 2
General Population Program total population: 14
Dementia-Specific Program tenants without cognitive disorder: 2
Dementia-Specific Program tenants with cognitive disorder: 7
Dementia-Specific Program total population: 9
Total census of Assisted Living Program: 23
Staff files reviewed: 5
Staff #4 employment application date: Nov 28, 2013
Staff #4 background check date: Dec 3, 2013
Staff #4 employment start date: Apr 4, 2014
Staff #5 employment start date: Jul 21, 2014
Staff #1 hire date: May 28, 2014
Staff #2 hire date: Mar 27, 2014
Staff #3 hire date: Sep 10, 2014
Staff #4 hire date: Apr 4, 2014
Staff #5 hire date: Jul 21, 2014
All staff in-service training date: Aug 28, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brett Olsen | Manager | Program manager who provided statements during interviews and was involved in staff disciplinary actions |
| Wendy E. Kuhse | RN, BS | Monitor conducting the evaluation visit |
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 4
Date: Jun 13, 2012
Visit Reason
The inspection was conducted as a Final Complaint Investigation and Recertification Monitoring Evaluation in response to allegations regarding tenant care and regulatory compliance at Whispering Willow Assisted Living.
Complaint Details
The complaint investigation was triggered by allegations including improper sanitization of blood sugar monitoring equipment, medication errors, inadequate tenant services, failure to follow diabetic diets, locked windows in memory care unit, and tenant property issues. Some allegations were substantiated, such as medication storage and administration issues, while others were not.
Findings
The investigation found multiple regulatory insufficiencies related to medication administration, storage, evaluation, service plans, and tenant rights. Some allegations were substantiated with observations of improper medication handling, incomplete evaluations, and inadequate service plans, while other areas showed no regulatory insufficiencies.
Deficiencies (4)
The administration of medications was not properly supervised and medications were not stored securely.
Tenant medications were not kept within their expiration date and medication planners were not properly marked.
Evaluations of tenants' functional, cognitive, and health status were not always completed annually or with significant changes in condition.
Service plans did not always meet the individualized needs of tenants and were not consistently updated based on evaluations.
Report Facts
Number of tenants without cognitive disorder in general population: 12
Number of tenants with cognitive disorder in general population: 1
Total population of general population program: 13
Number of tenants without cognitive disorder in dementia-specific program: 2
Number of tenants with cognitive disorder in dementia-specific program: 5
Total population of dementia-specific program: 7
Total census of Assisted Living Program: 20
Dates of complaint/incident investigation: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor involved in complaint/incident investigation |
| Lori Miner | RN BSN | Monitor involved in complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 13
Deficiencies: 3
Date: Dec 7, 2010
Visit Reason
The inspection was a final complaint revisit and recertification monitoring evaluation conducted due to regulatory insufficiencies related to medications and record checks at Whispering Willows Assisted Living.
Complaint Details
Complaint Intake #28042-CR. The complaint was substantiated with findings related to medication administration and record checks.
Findings
The report identified regulatory insufficiencies in medication administration and record checks, resulting in a $500 civil penalty. The program submitted a Plan of Correction which was accepted by the Department of Inspections and Appeals.
Deficiencies (3)
Medications were documented as given prior to administration, medications were not documented as given, handwashing was not done prior to administration, medications were set up in unlabeled medication cups, medication was administered more than one hour after the scheduled time, and topical medications were not separated in a zip lock bag.
The program received a regulatory insufficiency at the time of the September 2, 2009 on-site regarding unlocked cabinets with cleaning products accessible to tenants with dementia.
The program did not meet requirements for criminal background checks for prospective employees as required by Iowa code section 135C.33 and related administrative rules.
Report Facts
Civil penalty amount: 500
Days to request hearing or pay penalty: 30
Census count: 8
Census count: 0
Census count: 5
Total census: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brent Olsen | Director | Named as Director of Whispering Willow Assisted Living. |
| Lori Miner | RN BSN | Monitor conducting the evaluation. |
| Joyce Kix | RN | Monitor conducting the evaluation. |
| Rose Boccella | Certification Coordinator | Contact person for appeals and hearings. |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter. |
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 5
Date: Jun 16, 2010
Visit Reason
A complaint investigation was conducted at Whispering Willows Assisted Living due to allegations of unsecured cabinets containing cleaning products in a dementia specific unit bathroom.
Complaint Details
The complaint investigator observed unsecured cleaning products in a dementia specific unit bathroom and other areas posing potential accidental ingestion risks. The complaint was substantiated with regulatory insufficiencies noted.
Findings
The investigation found unsecured cleaning products posing potential threats of accidental ingestion in multiple locations including the memory care unit bathroom, kitchen area cabinet, housekeeping cart, and laundry room. A regulatory insufficiency was cited for structural requirements and general building maintenance.
Deficiencies (5)
Unsecured cleaning products in the community bathroom of the dementia specific unit posing potential threat of accidental ingestion.
Unsecured cleaning products in the kitchen area cabinet posing potential threat of accidental ingestion.
Unsecured cleaning products on housekeeping cart posing potential threat of accidental ingestion.
Unsecured cleaning products in the unlocked laundry room posing potential threat of accidental ingestion.
Regulatory insufficiency for general requirements: building and grounds not well-maintained, clean, safe and sanitary.
Report Facts
Civil penalty amount: 500
Reduced civil penalty amount: 325
Current number of tenants without cognitive disorder: 9
Current number of tenants with cognitive disorder: 2
Total Population of General Population Program: 11
Total Population of Dementia Specific Program: 3
Total Census of Assisted Living Program: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor of the complaint investigation |
| Connie Schaffer | Certification Coordinator | Contact person for appeals and civil penalty matters |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter and conclusion |
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 0
Date: Sep 2, 2009
Visit Reason
An on-site incident investigation was conducted at Whispering Willows Assisted Living following a reported tenant fall resulting in a fractured hip.
Complaint Details
The complaint involved Tenant #1, an 86-year-old who fell and fractured a hip, and Tenant #2, a 94-year-old who also fell and fractured a hip. Both incidents were reported appropriately. No regulatory insufficiencies were substantiated.
Findings
The investigation found no regulatory insufficiencies. Two tenants sustained fractured hips after falls, and appropriate reporting to the Department of Inspections and Appeals was confirmed.
Report Facts
Current number of tenants without cognitive disorder: 7
Current number of tenants with cognitive disorder: 1
Total Population of General Population Program: 8
Total Population of Dementia Specific Program: 4
Total Census of Assisted Living Program: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor conducting the incident investigation |
Inspection Report
Original Licensing
Census: 9
Deficiencies: 1
Date: Jun 24, 2009
Visit Reason
The visit was conducted as an initial certification and incident monitoring evaluation for Whispering Willow Assisted Living in Fredericksburg, IA.
Findings
The report found no substantiated regulatory insufficiencies related to tenant exclusion criteria but identified a regulatory insufficiency regarding the individualized service plan for tenants, specifically that the program did not consistently ensure service plans were individualized for tenants unable to plan their own activities.
Deficiencies (1)
The program did not consistently ensure the service plan would be individualized indicating at a minimum for those tenants who are unable to plan their own activities, including those tenants with dementia, planned and spontaneous activities based on the tenant's abilities and personal interests.
Report Facts
Current number of tenants without cognitive disorder: 4
Current number of tenants with cognitive disorder: 1
Total Population of General Population Program: 5
Total Population of Dementia Specific Program: 4
Total Census of Assisted Living Program: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Streepy | RN | Monitor conducting the initial certification and incident monitoring evaluation |
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