S0080 - 06/27/2019 - Assisted Living Program Statement of Deficiencies and Plan of Correction

Sep 12, 2026

Statement of Deficiencies and Plan of Correction for an Iowa assisted living provider identified as S0080, covering a survey completed on 06/27/2019. The report includes initial comments describing census counts for general and dementia-specific programs and references regulatory insufficiencies tied to complaint investigation #82868-C. It cites failure to ensure a newly hired registered nurse completed required delegation reviews within 60 days for two long-term employees, with specific findings from interview and record review and the provider’s corrective-plan documentation.

LanguageEnglish

CategoryForms

FormatPDF

Pages10

Reading Time4 min

AccessFree to download

Statement of Deficiencies and Plan of Correction

Provider Identification and Survey Date

Summary Statement of Deficiencies

# DEPARTMENT OF INSPECTIONS ANDAPPEALS | STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION | | (X1)PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
S0080 | (X2)MULTPLE CONSTRUCTION
A.BUILDING:_
B.WING | | (X3)DATE SURVEY
COMPLETED
C
06/27/2019 | | | --- | --- | --- | --- | --- | --- | --- | | STREETADDRESS,CITY,STATE,ZIP CODE
NAME OF PROVIDER OR SUPPLIER
209 W JEFFERSON
QHC MADISON SQUARELLC
WINTERSET,IA 50273 | | | | | | | | (X4)ID
PREFIX
TAG | SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCYMUST BE PRECEDED BY FULL
REGULATORY OR LSCIDENTIFYING INFORMATION) | | ID
PREFIX
TAG | PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVEACTION SHOULD BE
CROSS-REFERENCED TO THEAPPROPRIATE
DEFICIENCY) | | (X5)
COMPLETE
DATE | | A000
A058 | Initial Comments
Assisted Living Programs are defined by the type
of population served.The census numbers were
provided by the Program at the time of the
on-site.
General Population Program
Number of tenants without cognitive disorder:26
Number of tenants with cognitive disorder:2
Total Population of Program at time of on-site:28
Dementia-Specific Program by Dedication
Number of tenants without cognitive disorder:2
Number of tenants with cognitive disorder:5
Total Population of Program at time of on-site:7
TOTAL census of Assisted Living Program:35
There following regulatory insufficiencies were
cited during the investigation of Complaint
\#82868-C.
481-67.9(4)a Staffing
481-67.9(231B,231C,231D)Staffing.
67.9(4)Nurse delegation procedures.The
program's registered nurse shallensure certified
and noncertified staff are competent to meet the
individual needs of tenants.Nurse delegation
shall,at a minimum,include the following:
a.The program's newly hired registered
nurse shall within 60 days of beginning
employment as the program's registered nurse
document a review to ensure that staff are
sufficiently trained and competent in all tasks that
are assigned or delegated. | | A000
A058 | 08/14/
is8td
noxorec | | 19 | LABORATORYDIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE忆ng2 u g25ecmmarcap 890TSTATEFORM DIVISION OF HEALTH FACILITIES-STATE OF IOWA 6899WEKR11If continuation sheet 1 of 8 # FORM APPROVED DFPARTMFNT OF INSPFCTIONS AND APPEALS | STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION | | PRoM门 R PPiFRICID
(X1)
IDENTIFICATION NUMBER:
S0080 | (X2)MULTIPLECONSTRUCTION
A.BUILDING:_
B.WING_ | | (X3)DATE SURVEY
COMPLETED
C
06/27/2019 | | | --- | --- | --- | --- | --- | --- | --- | | NAME OF PROVIDER OR SUPPLIER
STREETADDRESS.CITY.STATE.ZIP CODE
209 W JEFFERSON
HCMADISON SOUARELLC
WINTERSET,IA 50273 | | | | | | | | (X4)ID
PREFIX
TAG | SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY ORLSC IDENTIFYING INFORMATION) | | ID
PREFIX
TAG | PROMDERS PLAN OF CORRECTION
(EACH CORRECTIVEACTON SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY) | | (X5)
COMPLETE
DATE | | A058
A063 | Continued From page 1
This REQUIREMENT is not met as evidenced
by:
Based on interview and record review the
Program failed to ensure the newly hired
Reqistered Nurse(RN)conducted a review within
60 days of employment to ensure 2 of 2 long
term employees reviewed were sufficiently
trained and competent in tasks(Staff E and Staff
D).Findings include:
On 6/25/19 the Administrator reported the RN
began employment with the Program on 8/22/18.
On 6/25/19 record review revealed Staff E was
hired by the facility on 11/28/2016 as a Universal
W

FAQs

What was the survey completion date for the provider’s report?

The report lists the survey completed on 06/27/2019.

What regulatory issue is cited regarding nurse delegation?

The report states the newly hired registered nurse did not complete delegation review requirements within 60 days to ensure certified and noncertified staff competence for assigned or delegated tasks.

How does the document describe the assisted living program census?

It provides tenant counts for both the general population program and the dementia-specific dedicated program at the time of the on-site.

Sep 12, 2026

Upload by Olivia Brown