Inspection Reports for Willows of Marshalltown Assisted Living
2315 Campbell Drive, Marshalltown, IA, 50158
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 26, 2024, identified deficiencies related to program policies, tenant rights, medications, staffing, service plans, evaluations, and nurse reviews. Earlier inspections showed a pattern of similar issues, including incomplete service plans, delayed evaluations, medication errors, and staff training gaps, with one substantiated complaint involving inadequate care and staff training during transportation. Inspectors cited problems mainly in care planning, medication administration, and staff training. Complaint investigations prior to the latest report were mostly unsubstantiated, except for one substantiated case involving injury due to improper wheelchair securing. The facility’s inspection history indicates ongoing challenges with compliance in key areas, with no clear improvement trend over time.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
3.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
40 residents
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 7
Date: Sep 26, 2024
Visit Reason
The inspection was initiated to investigate complaints #120381-C and #122375-C and to conduct a recertification visit to determine compliance with certification for an Assisted Living Program.
Complaint Details
Complaint #120381-C was investigated and cited for regulatory insufficiencies. The complaint involved issues with care staff documentation, incident reporting, wound care, medication administration, and nurse delegation training.
Findings
The facility was found to have multiple regulatory insufficiencies related to program policies and procedures, tenant rights, medications, staffing, service plans, evaluations, and nurse reviews. Specific issues included failure to follow established policies related to incident reports, inadequate treatment and services for wounds, medication administration errors, incomplete nurse delegation training, and failure to complete timely evaluations and service plans.
Deficiencies (7)
Program failed to follow established policies and procedures related to incident reports for Tenant #4.
Program failed to provide adequate treatment and services related to a wound for Tenant #3.
Program failed to ensure medications and treatments were administered as ordered for Tenants #1 and #3.
Program failed to complete nurse delegated training related to assistance with bathing when a wound vac was utilized for Tenant #3.
Program failed to complete evaluations within 30 days of taking occupancy for discharged tenants.
Program failed to update service plans as needed with significant changes for current tenants.
Program failed to complete nurse reviews every 90 days for current tenants.
Report Facts
Total census: 40
Number of tenants reviewed: 5
Number of tenants with wound issues: 1
Number of tenants with medication issues: 2
Number of tenants with evaluation deficiencies: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stanley | ED | Signed plan of correction and report on 11/26/2024 |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 0
Date: Dec 28, 2022
Visit Reason
Investigation of Complaint #107447-C at Willows of Marshalltown Assisted Living.
Complaint Details
Complaint #107447-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder: 34
Number of tenants with cognitive disorder: 6
Total census: 40
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 0
Date: May 12, 2022
Visit Reason
Investigation of Complaint #104604-C at Willows of Marshalltown Assisted Living.
Complaint Details
Complaint #104604-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Report Facts
Number of tenants without cognitive disorder: 37
Number of tenants with cognitive disorder: 3
Total Population: 40
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 6
Date: Aug 12, 2021
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification of an Assisted Living Program, as well as to investigate Incident #93201-I and Complaint #94494-C.
Complaint Details
The complaint investigation involved Incident #93201-I where Tenant #C1 was injured during a bus trip due to improper securing of the wheelchair. The incident was substantiated with findings of inadequate care and lack of staff training.
Findings
The facility was found to have multiple regulatory insufficiencies including failure to provide appropriate care and treatment to a tenant, failure to evaluate tenants within 30 days of occupancy, failure to develop and update service plans timely, and failure to ensure staff received appropriate training on securing wheelchairs during transportation.
Deficiencies (6)
Failure to provide appropriate care, treatment, and services to Tenant #C1 related to an incident during transportation.
Failure to evaluate Tenant #2's functional, cognitive, and health status within 30 days of occupancy.
Failure to develop a service plan prior to signing the occupancy agreement and taking occupancy for Tenants #1 and #2.
Failure to update service plans within 30 days of occupancy and as needed for significant changes for Tenant #2.
Failure to develop an individualized service plan indicating tenant needs and preferences for Tenant #C2.
Failure to ensure all personnel received appropriate training on how to secure a wheelchair during transportation.
Report Facts
Number of tenants without cognitive disorder: 33
Number of tenants with cognitive disorder: 3
Total population of program at time of onsite: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Facility Director | Named in findings related to the bus incident and lack of training on securing wheelchairs |
| Executive Director | Provided copy of transportation policy and confirmed lack of staff training | |
| Registered Nurse | Confirmed findings related to evaluations and service plans | |
| Director of Nursing | Director of Nursing | Responsible for corrective actions related to evaluation and service plans |
| Maintenance Director | Named as responsible person for corrective action related to wheelchair securing training |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 0
Date: Jul 30, 2020
Visit Reason
The inspection was conducted as an investigation of Incident #89216-I and included an onsite infection control survey.
Complaint Details
Investigation of Incident #89216-I found no regulatory insufficiencies.
Findings
No regulatory insufficiencies or deficiencies were cited during the investigation or the infection control survey completed on 2020-07-21.
Report Facts
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 0
Total Population: 27
Inspection Report
Annual Inspection
Census: 18
Deficiencies: 3
Date: Dec 6, 2018
Visit Reason
The inspection was conducted to determine compliance with certification rules for an Assisted Living Program, including review of occupancy agreements, service plans, and food service requirements.
Findings
The inspection found multiple regulatory insufficiencies including incomplete tenant occupancy agreements, failure to obtain required signatures on service plans for some tenants, failure to update service plans with significant changes, and inadequate food safety training for staff.
Deficiencies (3)
Failure to obtain signatures from all parties who developed the service plan prior to admission for 2 of 4 tenants reviewed.
Failure to update service plans as required for 1 of 1 tenant reviewed with a significant change.
Failure to provide orientation on sanitation and safe food handling prior to handling food for 7 of 11 staff reviewed.
Report Facts
Number of tenants without cognitive disorder: 15
Number of tenants with cognitive disorder: 3
Total Population of Program at time of on-site: 18
Number of staff lacking food safety training: 7
Number of staff reviewed for food safety training: 11
Number of tenants reviewed for service plan signatures: 4
Number of tenants reviewed for service plan updates: 1
Viewing
Loading inspection reports...
