Inspection Reports for Wilton Retirement Community
307 Ovesen Drive, IA, 52778
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 31, 2025, identified a deficiency related to unsecured medications for five cognitively impaired residents and inadequate supervision during medication administration. Earlier inspections showed a pattern of deficiencies involving medication management, care planning, infection control, and reporting of resident incidents. Complaint investigations were generally unsubstantiated, though prior reports noted failures in notification and investigation of resident altercations. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows recurring issues primarily with medication security and care documentation, with no clear trend of consistent improvement or worsening over time.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
29 residents
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 29
Deficiencies: 1
Dec 31, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey from December 29, 2025 to December 31, 2025.
Findings
The facility failed to secure medications properly for 5 cognitively impaired, independently mobile residents in the Chronic Confusion and Dementing Illness unit, resulting in a potential hazard. Staff did not adequately supervise residents during medication administration, allowing medications to be left unattended.
Severity Breakdown
SS = D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to secure medications to prevent a potential hazard for 5 cognitively impaired, independently mobile residents in the CCDI unit. | SS = D |
Report Facts
Census: 29
Residents with medication hazard: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Assistant (CMA) | Placed medications in a cup and left them unattended during administration |
| Staff B | Certified Nursing Assistant (CNA) | Sat across from resident but left medications unattended |
| Staff C | Certified Medication Assistant (CMA) | Stated staff should not leave medications with residents |
| Staff D | Registered Nurse (RN) | Stated staff should watch residents take medications and would never leave medications with residents |
| Director of Nursing | Director of Nursing (DON) | Expressed concern that staff did not watch medication ingestion and planned to follow up |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 31, 2024
Visit Reason
The document serves as a Plan of Correction following a survey ending on 2024-10-10, addressing the facility's compliance status.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective 2024-10-21.
Inspection Report
Annual Inspection
Census: 30
Deficiencies: 1
Oct 10, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey from October 7, 2024 to October 10, 2024.
Findings
The facility failed to ensure proper handwashing and equipment sanitizing between tasks during the puree food preparation process, as observed with Staff A. The Dietary Supervisor confirmed the deficiency and noted prior training and re-education efforts for the staff involved.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to complete handwashing and equipment sanitizing between tasks during the puree food preparation process. | SS=D |
Report Facts
Census: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chad Thomas | Administrator | Signed the plan of correction |
| Staff A | Dietary Aide | Observed failing to wash hands and sanitize equipment properly during food preparation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 20, 2024
Visit Reason
A complaint investigation for Complaint #114941-C was conducted from February 29, 2024 to March 20, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #114941-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 4, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's certification compliance.
Findings
Based on acceptance of the credible allegation of compliance and plan of correction, the facility will be certified in compliance effective August 4, 2023.
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 5
Jul 20, 2023
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification survey and investigation of Facility Reported Incidents #114285-I from July 17, 2023 to July 20, 2023.
Findings
The facility was found deficient in multiple areas including failure to ensure current Dependent Adult Abuse training for one staff member, untimely submission of a Significant Change Minimum Data Set (MDS) assessment, inaccuracies in coding medical diagnoses and medications on MDS for several residents, failure to address anticoagulant therapy in a care plan, and failure to offer the recommended pneumococcal vaccine to a resident.
Severity Breakdown
SS=D: 4
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure one of five staff members had current Dependent Adult Abuse training. | SS=D |
| Failed to submit a Significant Change Minimum Data Set (MDS) assessment timely for 1 of 12 reviewed residents. | SS=D |
| Failed to correctly code medical diagnoses and medications on the MDS for 4 of 5 residents reviewed for unnecessary medications. | SS=E |
| Failed to address anticoagulant therapy on the care plan for 1 of 12 residents reviewed for care planning. | SS=D |
| Failed to offer the recommended pneumococcal vaccine for 1 of 6 residents reviewed for pneumococcal vaccine status. | SS=D |
Report Facts
Facility census: 32
Residents reviewed for MDS submission: 12
Residents reviewed for unnecessary medications: 5
Residents reviewed for care planning: 12
Residents reviewed for pneumococcal vaccine status: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in deficiency for failure to have current Dependent Adult Abuse training |
| Director of Nursing | Interviewed regarding MDS submission timeliness, medication coding, care planning, and pneumococcal vaccine offering | |
| MDS Coordinator | Interviewed regarding MDS coding and care planning deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 0
May 25, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance of the facility.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective May 25, 2023. No specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 3
Apr 26, 2023
Visit Reason
Investigation of complaints related to resident to resident altercations and failure to notify physician and family, and failure to report alleged violations to the state.
Findings
The facility failed to notify the physician and family after a resident to resident altercation involving Resident #12 and Resident #13, failed to report the incident to the Iowa Department of Inspection and Appeals (DIA), and failed to conduct a thorough investigation of the incident. Resident #12 exhibited repeated inappropriate sexual behaviors toward female residents, including Resident #11 and Resident #13. Documentation and communication regarding these behaviors were inadequate, and staff lacked training and clear procedures for reporting and investigating such incidents.
Complaint Details
Complaint #107841-C was investigated from April 24 to April 26, 2023 and was not substantiated.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to notify physician and family after resident to resident altercation involving Resident #13. | SS=D |
| Failure to report resident to resident altercation to Iowa Department of Inspection and Appeals for 3 residents. | SS=D |
| Failure to conduct a thorough investigation of resident to resident altercations for 3 residents. | SS=D |
Report Facts
Resident census: 30
Number of residents sampled: 3
BIMS scores: 5
BIMS scores: 13
BIMS scores: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Practical Nurse (LPN) | Documented inappropriate sexual comments by Resident #12 and intervened during incident on 4/09/23 |
| Staff A | Registered Nurse (RN) | Reported incident reporting procedures and requirements for resident altercations |
| Staff C | Registered Nurse (RN) | Reported incident reporting procedures and lack of formal training on reporting sexual behaviors |
| Staff G | Certified Medication Aide (CMA) | Reported observations of Resident #12's inappropriate sexual behaviors and interventions |
| Staff H | Certified Nursing Assistant (CNA) | Reported Resident #12's inappropriate sexual behaviors toward Resident #13 |
| Staff D | Licensed Practical Nurse (LPN) | Reported incident reporting procedures and involvement in investigations |
| Staff E | Licensed Practical Nurse (LPN) | Reported no concerns but notified DON of Resident #12's inappropriate sexual comments |
| Director of Nursing (DON) | Director of Nursing | Did not recognize incident as altercation, had not completed investigation or incident report, planned education for staff |
| Administrator | Facility Administrator | Reported incident had not been reported to state, planned education for staff, and described QA use of communication notebook |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 13, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's certification compliance.
Findings
Based on acceptance of the credible allegation of compliance and plan of correction, the facility will be certified in compliance effective July 10, 2022. No deficiencies are detailed in this document.
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 7
May 23, 2022
Visit Reason
The inspection was a recertification survey conducted from 5/16/22 through 5/23/22 to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to assess residents for self-administration of medications, late submission of Minimum Data Set (MDS) assessments, incomplete and untimely updates to comprehensive care plans, inadequate documentation and assessment related to hospital transfers, improper catheter care including tubing touching the floor and lack of dignity bag use, and failure to follow infection control practices such as changing gloves during wound care.
Severity Breakdown
SS=D: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to assess a resident for self-administration of medications before leaving medications with the resident. | SS=D |
| Failed to submit Minimum Data Set (MDS) assessments in a timely manner for two residents. | SS=D |
| Failed to include wandering, risk for elopement, and antidepressant medication use in the comprehensive care plan for a resident. | SS=D |
| Failed to update care plans timely to include diagnoses of diabetes, catheter use, and removal of antidepressant medication for three residents. | SS=D |
| Failed to document assessment of a resident prior to and upon return from hospital stay. | SS=D |
| Failed to ensure catheter tubing was kept off the floor and catheter bags were placed in dignity bags for residents with catheters. | SS=D |
| Failed to follow infection prevention and control practices including failure to wear gloves prior to handling catheters and failure to change gloves during wound care. | SS=D |
Report Facts
Residents reviewed: 14
Residents reviewed: 3
Residents reviewed: 2
Census: 34
MDS late submission days: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Named in medication administration and catheter care findings |
| Staff B | Registered Nurse | Named in catheter care and wound care findings |
| Staff C | Certified Nurse Aide | Named in catheter care findings |
| Staff D | Certified Nurse Aide | Named in catheter care findings |
| Staff E | Certified Nurse Aide | Named in catheter care findings |
| Staff F | Certified Nurse Aide | Named in catheter care findings |
| Staff G | Certified Nurse Aide | Named in catheter care findings |
| Director of Nursing | Director of Nursing | Named in multiple findings including medication administration, MDS submission, care planning, catheter care, and infection control |
Inspection Report
Annual Inspection
Census: 25
Deficiencies: 2
Sep 24, 2020
Visit Reason
The inspection was conducted as an annual recertification survey combined with a COVID-19 Focused Infection Control survey to assess compliance with CMS and CDC recommended practices.
Findings
The facility was found to be in compliance with COVID-19 infection control practices. However, deficiencies were identified related to failure to develop and implement comprehensive care plans addressing PRN anti-anxiety medications, hospice services, and cast care for certain residents. Additionally, the facility failed to document attempts of non-pharmacological interventions prior to administering PRN anti-anxiety medications for one resident.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to address and identify interventions in care plans for 3 of 12 residents regarding PRN anti-anxiety medications, hospice services, and cast care. | SS=D |
| Failed to document attempts of non-pharmacological interventions prior to administering PRN anti-anxiety medications for one resident. | SS=D |
Report Facts
Total Census: 25
Residents reviewed: 12
PRN anti-anxiety medication administrations without documented non-pharmacological interventions: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (Staff B) | Reported expectations for care plan interventions and documentation for PRN anti-anxiety medications and hospice services | |
| Licensed Practical Nurse, MDS Coordinator (Staff A) | Responsible for developing and updating care plans; reported expectations for care plan interventions | |
| Director of Nursing (DON) | Reported expectations for care plan content and documentation of interventions for PRN medications, hospice services, and cast care |
Inspection Report
Abbreviated Survey
Census: 23
Deficiencies: 0
Jun 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 23
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 10, 2020
Visit Reason
The inspection was conducted to investigate two facility self-reported incidents (#85636 and #86904) during the period of 2/5-2/10/2020.
Findings
The investigations of the two self-reported incidents were not substantiated according to the report.
Complaint Details
The facility self-reported incidents #85636 and #86904 were investigated and found not substantiated.
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